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Principles  of  Surgery, 


N.   SKNN,    M.E).,  Ph.D., 

Professor  Pki.nciples  of  Scrgery  axd  Surgical  Pathology  in  the  Risk  ilEuiCAL  College,  Chicago,  III. 

Professor  of  Surgery  in  the  Chicago  Polyclinic;  Atte.vding  Surgeo.v  to  the  Milwaukee  Hospital; 

Consulting  Surgeon  to  the  Milwaukee  County  Hospital  and  to  the  Milwaukee  County 

Insane  Asylum;   Honorary  Fellow  College  of  Physicians  in  Philadelphia,  Pa.: 

Member  of  the  American  Surgical  Association,  of  the  American  Medical 

Association,  of  the  British   Medical  Association,   of  the 

Wisconsin  State  Medical  Society,  etc. 


ILLUSTRATED   WITH    109   WOOD-ENGRAVINGS. 


PHILADELPHIA   AND   LONDON : 

F.    A.    DAVIS,    PUBLISHER, 
1890. 


3/ 
60S' 


Entered  according  to  Act  of  Congress,  in  the  vear  1890,  by        * 
F.  A.  DAVIS, 
In  the  Office  of  tlie  Librarian  of  Congress,  at  Washington,  D.  C,  U.  S.  A. 


Philadelphia,  Pa.,  XT.  S.  A. 

The  Medical  Bulletin  Printing  House, 

1231  Filbert  Street. 


I 

^    .  PREFACE 


A  iMODERN  work  on  the  principles  of  surgen^  in  the 
English  language  has  become  a  generally  and  well-recognized 
necessity.  The  recent  great  discoveries  relating  to  the  etiology 
and  pathology  of  surgical  diseases  have  made  the  text-books  of 
only  a  few  years  ago  old  and  almost  worthless.  The  many 
treatises  on  surgery,  by  American  and  English  authors,  which 
have  made  tlieir  appearance  in  rapid  succession  during  the  last 
ten  years  or  more,  are  replete  with  valuable  practical  information, 
but  most  of  them  are  defective  in  those  parts  relating  to  the 
matter  treating  of  the  fundamental  principles  of  the  art  and 
science  of  surgery. 

It  has  been  my  aim  to  write  a  book  for  the  student  and 
general  practitioner  which  should,  at  least  in  part,  fill  this  gap 
in  surgical  literature,  and  which  should  serve  the  purpose  of  a 
systematic  treatise  on  the  causation,  pathology,  diagnosis,  prog- 
nosis, and  treatment  of  the  injuries  and  affections  which  the 
surgeon  is  most  frequently  called  upon  to  treat.  The  successful 
study  and  practice  of  any  branch  of  the  healing  art  require  a 
thorough  knowledge  of  the  principles  upon  which  it  is  based. 
The  student  who  has  mastered  the  principles  of  surgery  will 
have  no  difficulty  in  applying  his  knowledge  in  practice,  while 
the  one  who  has  burdened  his  memory  with  numerous  details 
to  meet  special  indications  is  always  at  a  loss  in  making  prompt 
and  judicious  use  of  his  therapeutic  resources  when  confronted 
by  rare  lesions  or  unexpected  emergencies. 

(iii) 


IV  PREFACE. 

In  writing  this  book  it  has  been  my  intention  to  keep  in 
constant  view  the  difference  between  the  cellular  processes,  as 
we  observe  them  in  regeneration  and  inflammation,  and  to 
connect  the  modern  science  of  bacteriology  more  intimately  with 
the  etiology  and  pathology  of  surgical  affections  than  has  here- 
tofore been  done  by  most  authors  who  have  written  on  the 
same  subjects.  In  showing  the  direct  etiological  relationship 
which  exists  between  certain  pathogenic  micro-organisms  and 
definite  pathological  processes,  I  have  frequently  made  liberal 
use  of  the  experimental  and  clinical  material  contained  in  my 
work  on  "  Surgical  Bacteriology."  When  the  subject  of 
tumors  was  reached  it  was  found  that  the  manuscript  had 
become  so  voluminous  that  it  was  deemed  advisable  to  publish 
the  volume  without  this  part  of  the  intended  scope  of  the 
work, — an  arrangement  to  which  the  publisher  kindly  gave  his 
consent.  It  is  the  author's  intention  to  make  good  this  defect 
by  the  preparation,  in  the  near  future,  of  a  special  work  on 
"  The  Pathology  and  Surgical  Treatment  of  Tumors." 

With  few  exceptions  the  sources  from  which  my  informa- 
tion was  taken  are  not  given,  as  a  copious  bibliography  would 
have  required  considerable  valuable  space.  At  the  same  time 
the  author  hopes  that  he  has  presented  the  views  and  opinions 
of  the  authorities  quoted  with  sufficient  clearness  and  thorough- 
ness to  render  a  resort  to  the  original  articles,  in  most  instances, 
unnecessary.  Among  the  text-books  which  I  have  consulted  I 
desire  to  mention  the  following  :  Histology  :  Klein,  Schafer, 
Heitzmann,  and  Satterthwaite.  Pathology:  Klebs,  Hamilton, 
Birch-Hirschfeld,  Paget,  Virchow,  Coates,  Lebert,  Rindfleisch, 
Delafield,  and  Prudden.  The  Principles  of  Surgery:  Konig, 
Hueter-Lossen,  Landerer,  Billroth- Winiwarter,  and  Van  Buren. 
Bacteriology :    Fluegge,  Baumgarten,  and    Cruikshank.      The 


PREFACE.  V 

illustrations  were  selected  from  modern  text-books  not  readily 
accessible  to  the  average  student. 

A  prolonged  absence  from  home  made  it  impossible  for  the 
author  to  attend  to  the  proof-reading,  and  he  asks  the  indulg- 
ence of  the  reader  for  any  imperfections  which  may  appear  in 
the  book  from  any  sources  for  which  he  cannot  be  held  person- 
ally responsible. 

Should  this  volume  become  the  means  of  lightening  and 
facilitating  the  student's  work  in  acquiring  a  thorough  knowl- 
edge of  the  fundamental  principles  of  surgery,  and  of  serving  as 
a  useful  source  of  information  for  the  busy  general  practitioner, 
the  author  will  feel  abundantly  rewarded  for  the  many  sleepless 
nights  which  were  required  in  its  preparation. 

N.  Senn. 

MiLWACKKB,  October,  1890. 


TABLE  OF  CONTENTS. 


PAGE 

Preface, iii 

Table  of  Contents. vii 

List  of  Illustrations, xi 

CHAPTER   I. 
Regeneration, 1 

CHAPTER   II. 

Regeneration  of  Different  Tissues, 31 

CHAPTER   III. 

Inflammation, 67 

CHAPTER   IV. 
Inflammation  {continued), 93 

CHAPTER  V. 
Pathogenic  Bacteria .127 

CHAPTER  VI. 

Necrosis,   .         .         .         .         .         .         .         .         .         .         .         .157 

CHAPTER   VII. 

Necrosis  (continued),        .         .         .         .         .         .         .         .         .17;') 

(vii) 


VI 11  TABLE    OF    COiN TENTS. 

CHAPTER   VIII.  PAGK 

Suppuration, 191 

CHAPTER   IX. 
Suppuration  {continued),  .         .         .        .         .        .         .         .20'.' 

CHAPTER   X. 

Suppurative  Osteomyelitis,     .         . 231 

CHAPTER   XI. 

SuppuRATiuiN  IN  Large  Cavities;    Abscess  of  Internal  Organs,     259 

CHAPTER   XII. 

SEPTICiEMIA, 30o 

CHAPTER   XIII. 
Pyemia, 333 

CHAPTER   XIV. 
Erysipelas, 359 

CHAPTER   XV. 
Tetanus, 383 

CHAPTER    XVI 
Hydrophobia, .        .        .        •     403 

CHAPTER    XVII. 
Surgical  Tuberculosis 419 

CHAPTER   XVIII. 
Clinical  Forms  of  Surgical  Tuberculosis,    .        .  .        .447 


TABLE    Oi'    (UNTENTS.  ix 

CHAPTER   XIX.  PASE 

Tuberculosis  of  Lymphatic  Glands  and  Peritoneum,  .        .        .     469 

CHAPTER   XX. 
Tuberculosis  of  Bones  and  Joints, 489 

CHAPTER   XXI. 

Tuberculosis  of  Tendon-Sheaths,  etc., 525 

CHAPTER   XXII. 

Actinomycosis  Ho.minis, 549 

CHAPTER    XXIII. 
Anthrax, 571 

CHAPTER   XXIV. 
Gj.anders, 589 

Index, 603 


LIST  OF  ILLUSTRATIONS. 


FIG.  PAGE 

1.  A  wound  twenty-six  hours  old  (Thiersch), 4 

2.  "                 "                "                  "                5 

3.  Quiescent  nucleus  (Fleming),          . 8 

4.  Living  cell  of  salamander  (Fleming), 8 

5.  Endothelial  cells  (Fleming), 9 

6.  Epithelial  cell  of  salamander  (Fleming), 10 

7.  "                         "                     "                  10 

8.  "                         "                     "                  11 

9.  Cell  division  (McKendrick), 13 

10.  Granulating  wound  (Billroth- Winiwarter), 14 

11.  Granulation  tissue  from  wound  (Hamilton), 15 

13.  Superficial  capillaries  of  a  wound  beginning  to  granulate  (Hamilton),          .         .  17 

13.  Formation  of  new  blood-vessels  by  budding  (Arnold), 18 

14.  Development  of  blood-corpuscles  in  connective-tissue  cells,  and  transformation 

of  the  latter  into  capillary  blood-vessels  (Fluegge), 19 

15.  Granulating  wound  undergoing  cicatrization  (Landerer), 20 

16.  Embryonal  connective-tissue  cell  undergoing  transformation  into  mature  state 

(Ziegler), 21 

17.  Wandering  epithelial  cells  from  frog  (Klebs), 22 

18.  Corneal  corpuscles  in  a  state  of  proliferation  (Senftleben), 33 

19.  Wound  of  cornea  (vou  Wyss), 34 

20.  Rhinoplasty  and  transplantation  of  large  skin-grafts  (Thiersch),  ....  40 

21.  Microscopical  appearances  of  the  interior  of  artery  of  dog, 43 

22.  Microscopical  appearances  of  the  interior  of  vein  of  dog, 44 

23.  Femoral  artery  of  dog, 45 

24.  Muscular  fibres  near  a  wound  in  a  state  of  proliferation  (0.  Weber),    ...  48 

25.  Section  through  callus  (Bajardi), 51 

26.  Transverse  section  through  callus  (Maas), .52 

27.  Nerve-fibre  in  state  of  regeneration  (Gluck), 61 

28.  Longitudinal  section  through  nerve  (Gluck), 62 

29.  Nerve  suture,  showing  application  of  direct  and  paraneurotic  sutures,          .        .  63 

30.  Capillary  vessels  of  the  frog's  mesentery  (Klein), 69 

31.  Leucocyte,  showing  reticulum  of  protoplasmic  strings  (Klein),     ....  70 

32.  Change  of  forms  of  a  moving  leucocyte  by  amoeboid  movements  (Klein),    .        .  71 

33.  Third  corpuscle  (Eberth  and  Schimmelbusch),       .        .         .....  72 

34.  Normal  circulation  in  frog's  web  (Landerer),          . 78 

35.  Capillaries  of  frog's  web  in  a  state  of  hypersemia  (Landerer),       ....  79 

36.  Leucocyte  passing  through  capillary  wall  (Landerer), 86 

37.  Inflammation  of  frog's  web  at  stage  where  capillary  stream  is  impeded  by  com- 

mencing emigration  (Landerer),         88 

88.  Germinating  endothelium  (Hamilton), 97 

(Xi) 


XI 1  LIST    OF    ILLFSTRATTONS. 

KlU.  PAGE 

39.  Omentum  of  young  dog,  experimentally  Inflamed  (Hamilton),      .         .         .         .98 

40.  Aeute  pleurisy  (Hamilton), 99 

41.  Artificial  keratitis  (Hamilton), 106 

42.  Phagocytosis, Ill 

43.  Different  forms  of  bacteria  (Baumgarten), 128 

44.  Endogenous  spore  production  in  bacillus  anthracis  (Baumgarten),         .         .         .  130 

45.  Spore  of  bacillus  of  anthrax  (De  Bary), 131 

4fi.  Gelatin  cultures  following  surface  inoculation  (Fluegge), 132 

47.  Cultures  in  gelatin  growing  in  tlie  track  made  by  the  needle  (Fluegge),       .         .  133 
4S.  Experimentally-produced  growth  of  streptococci  in  centre  of  cornea  of  rabbit 

(Baumgarten), 161 

49.  Microscopic  pictures  of  staphylococcus  (Rosenbach), 301 

.50.  Micrococcus  pyogenes  tenuis,  cultivated  from  pus  in  a  case  of  empyema  (Rosen- 
bach), 203 

.51.  Microscopic  picture  of  streptococcus  pyogenes  (Rosenbach),          ....  203 

.52.  Bacillus  pyogenes  foetidus  (Fluegge), 204 

.53.  Bacillus  pj'ocyaneus  (Fluegge), 204 

54.  White  corpuscles  and  pus-corpuscles  (Koch), 206 

55.  Fragmentation  of  nucleus  in  leucocytes  undergoing  transformation  into  pus- 

corpuscles  (Landerer), 207 

.56.  Pus  with  staphylococcus  (Fluegge), 208 

.57.  Pus  with  streptococcus  (Fluegge), 208 

58.  Pus-corpuscles  (Billroth-Winiwarter), 208 

.59.  Infiltration  of    connective  tissue  of  cutis,  with  beginning  suppuration  in  the 

centre  (Billroth- Winiwarter), 213 

60.  Vessels  (artificially  injected)  from  walls  of  an  abscess  artificially  produced  in  the 

tongue  of  a  dog  (Billroth-Winiwarter), 214 

61.  Gonococcus  (Bumm), 260 

62.  Motor  areas  (London  Lancet), 274 

63.  Wilson's  cyrtometer  (Loudon  Lancet), 276 

64.  Wilson's  cyrtometer  applied  (London  ianceO) 276 

65.  Head,  skull,  and  cerebral  fissures  (adapted  from  Marshall), 277 

66.  Vein  of  the  diaphragm  of  a  septicaemic  mouse  (Koch), 305 

67.  Glomerulus  of  a  septicsemic  rabbit  (Koch), 807 

68.  Capillary   vessels   surrounding    the   Intestinal   glands  of   a   septicsemlc   rabbit 

(Koch), 308 

69.  Bacillus  of  malignant  oedema  (Koch), 309 

70.  Spore  formation  in  bacillus  of  malignant  cedema(Fluegge), 309 

71.  Cultures  of  bacillus  of  malignant  oedema  in  gelatin  (Fluegge),    .         .         .         .310 

72.  Bacillus  saprogenes  1  (Rosenbach), 315 

73.  Bacillus  saprogenes  2  (Rosenbach), 315 

74.  Bacillus  saprogenes  3  (Rosenbach), •         •         •  315 

75.  Proteus  vulgaris  (Hauser), 316 

76.  Proteus  mirabilis  (Hauser), 317 

77.  Involution  forms  of  proteus  mirabilis  (Hauser),     .         .         •         ■         •         •         .318 

78.  Vessel  from  the  cortex  of  the  kidney  of  a  pysemic  rabbit  (Koch),  .        .        .336 

79.  Laminated  thrombus  in  a  vein  (Birch-Hirschfeld), 342 

80.  Thrombo-phlebltis  (Billroth), 343 

81.  Embolus  of  branch  of  pulmonary  artery  (Birch-Hlrechfeld),         .        .         .         .345 

82.  Pysemic  abscess  of  lung  (Hamilton), 346 

83.  Coagulation  necrosis  from  a  kidney  infarct  (Birch-Hirschfeld),     .         .         .         .347 

84.  Pysemic    pus,   showing   complete    nuclear    destruction    in    corpuscles    and    an 

abundance  of  pus-microbes  within  and  between  pus-corpuscles  (Landerer),    .  351 


LIST    OF    ILLUSTRATIONS.  XUl 

FIQ.  I'AGK 

85.  Section  of  ear  of  rabbit  parallel  to  surface  of  cartilage.     The  morbid  process 

resembled  erj'sipelas  (Koch), 360 

86.  Streptococcus  erysipelatosus  (Baumgarten), 361 

87.  Stale  culture  of  streptococcus  of  erysipelas  in  gelatin  (Baumgarten),    .         .         .  362 

88.  Section  through  skin  near  the  margin  of  the  erysipelatous  zone  (Koch),       .        .  36.^ 

89.  Tetanus  bacilli  (Frankel-Pfeift'er), 384 

90.  A  blood-vessel  from  medulla  oblongata  in  a  case  of  hydrophobia  (Coates),  .         .  411 

91.  From  the  salivary  gland  in  a  case  of  hydrophobia  (Coates), 412 

93.  Tubercle  bacilli  containing  spores  (Koch), 423 

93.  Giant  cell  with  one  tubercle  bacillus  (Fluegge), 424 

94.  Giant  cell.     Miliary  tuberculosis  (Fluegge), 424 

9.5.  Cover-glass  preparation  from  phthisical  sputum  (Baumgarten),     ....  425 

96.  Giant  cell  from  centre  of  tubercle  of  lung  (Hamilton), 438 

97.  Section  from  mucous  membrane  of  pharynx,  showing  epithelioid  cells  with  a  few 

small  giant  cells  (Birch-Hirschfeld), 440 

98.  Fully-developed  reticular  tubercle  of  lung  (Hamilton), 441 

99.  Ray-fungus,  with  one  of  the  rays  more  projecting  and  branching  (Ponflck),        .  550 

100.  Actinomyces.     Section  from  actinomycotic  swelling  (Fluegge),     ....  554 

101.  Actinomyces  from  lung  of  cow  (Marchand), 563 

102.  Anthrax  bacilli.     Spore  formation  and  spore  germination  (Koch),         .         .         .  572 

103.  Stab  culture  of  anthrax  bacilli  in  gelatin  (Baumgarten), 573 

104.  Anthrax  colony  upon  gelatin  (Fluegge), 574 

105.  Intestinal  villus  of  anthracic  rabbit  (Koch), 575 

106.  Anthrax  (Fluegge), 582 

107.  Bacilli  of  glanders  from  a  j'oung  potato  culture  (Baumgarten),    ....  590 

108.  Glanderous  nodule  from  the  liver  of  a  field-mouse  (Baum-garten),         .         .        .  592 

109.  Acute  glanders,  involving  nose  and  face,  showing  extent  of  local  lesions  (Birch- 

Hirschfeld),          598 


PRINCIPLES  OF  SURGERY. 


CHAPTER   I. 

Regeneration. 

Regeneration  includes  a  multitude  of  processes  which  are  intended 
to  repair  the  normal  phj'siological  waste  of  the  tissues  in  the  living  body 
or  to  restore  tissues  lost  b}-  injur}-  or  disease.  In  the  human  body 
normal  regeneration  or  repair  of  tissues  is  a  physiological  process,.which 
is  essential  for  the  maintenance  of  the  anatomical  perfection  and  func- 
tional activity  of  the  different  tissues  and  organs.  In  a  condition  of 
perfect  health,  in  the  full-grown  bod}',  the  normal  waste  incident  to  the 
increasing  activity  of  the  tissues  is  balanced  I)}'  this  reparative  process, 
while  during  the  development  of  the  bod}-  an  excess  of  material  is  added 
upon  which  depends  the  increase  of  tissue  which  constitutes  growth. 
If  cell-destruction  is  in  excess  of  cell-reproduction  atropln'  is  the  inevi- 
table result,  and  if  the  function  of  regeneration  is  comi^letel}-  suspended 
death  must  necessaril}-  ensue,  the  blood  being  the  first  tissue  the  seat  of 
extreme  atrophic  changes,  soon  to  be  followed  b}'  similar  changes  in  all 
the  tissues,  resulting  in  diminution  of  function  proportionate  to  the  de- 
gree of  atrophy,  and,  finally,  death  from  marasmus. 

Studied  from  a  surgical  aspect,  regeneration  includes  the  process 
observed  in  the  healing  of  wounds  produced  by  a  trauma  and  the  com- 
plete or  partial  restoration  of  parts  damaged  or  destro^'ed  by  the  action 
of  chemical  substances,  extremes  of  cold  or  heat,  and  the  various  de- 
structive inflammatory  processes  caused  b}-  the  presence  of  specific 
pathogenic  micro-organisms.  Regeneration  and  inflammation  are  dis- 
tinct conditions,  which  should  no  longer  be  confounded  or  considered 
from  the  same  etiological  and  pathological  stand-point.  An  ideal  regen- 
eration takes  place  without  inflammation  provided  the  seat  of  injury  or 
tissue-destruction  remains  aseptic  ;  that  is,  free  from  pathogenic  microbes. 
On  the  other  hand,  a  regenerative  process  within  or  around  an  inflamma- 
tory focus  can  only  be  established  in  tissues  in  which  the  cause  which 
has  produced  the  inflammation  has  not  been  sufficientl}'  intense  to  destro}^ 
the  proto|)lasm  of  the  cells.  Under  these  circumstances  the  reparative 
process  is  initiated  at  a  time  when  the  cause  which  has  given  rise  to  the 

(1) 


2  PRINCIPLES   OP   SUPOKKV. 

inflammation  lias  ceased  to  be  active,  or  in  tissues  not  deprived  of  theil* 
vegetative  power  by  its  action.  In  a  circumscribed  suppurative  inflam- 
mation the  cells  exposed  to  the  direct  action  of  the  pus-microbes  and 
their  ptomaines  are  destroyed,  and  the  process  of  repair  starts  from  th( 
abscess-walls  and  their  immediate  vicinity,  from  tissues  which  have  re- 
tained their  power  of  cell-i)rol iteration.  An^'^  organ  the  seat  of  a  tuber- 
cular infection,  in  which  the  parasitic  cause  is  not  sulficientl}'  intense  to 
destroy  the  vitality  of  the  cells,  retains  its  normal  structure  and  function 
b}^  virtue  of  this  intrinsic  power  of  regeneiation  of  its  cells.  All  repara- 
tive processes  consist  of  homologous  cell-development,  and  the  new 
tissue  resembles,  anatomically  and  phj'siologicall}-,  the  fixed  cells  from 
which  it  is  produced.  The  legitimate  succession  of  cells  is  now  a  well- 
established  law  in  pathology  as  well  as  embryology,  and,  according  to 
this  tissue,  is  never  produced  b}'  substitution  of  function.  According 
to  this  histogenetic  law,  each  cell-element  possesses  an  intrinsic  vegeta- 
tive power  from  the  earliest  embr3'onal  elevelopment  throughout  life, 
which,  in  case  of  loss  of  tissue  b^^  injury  or  disease,  enables  it  to  produce 
its  owni  kind  and  never  any  other  materially  different  histological  struc- 
ture. In  conformity  with  this  general  law  of  tissue-production,  an  injur}- 
or  defect  of  a  nerve-fibre  is  repaired  by  proliferation  from  pre-existing 
cells  which  compose  this  structure,  epithelial  cells  are  produced  only  by 
epithelial  cells,  new  vessels  are  formed  from  cells  which  exist  in  a  normal 
vessel-wall,  etc.     From  this  stand-point  will  be  considered — 

I.    HEALING    OF   WOUNDS. 

A  wound  may  be  defined  as  a  sudden  solution  of  continuit}-  of  any 
of  the  tissues  of  the  body  caused  by  the  application  of  mechanical  force. 
A  wound  is  open  or  subcutaneous  according  as  the  surface  covering  the 
skin  or  mucous  membrane  has  been  cut  or  torn  or  has  remained  intact. 
Since  the  introduction  of  the  antiseptic  treatment  of  wounds,  the  classi- 
fication into  open  and  subcutaneous  wounds  is  no  longer  of  the  same 
practical  importance,  as  an  open  wound,  under  careful  antiseptic  treat- 
ment, is  at  once  placed  under  the  same  favorable  conditions  for  a  satis- 
factory and  rapid  healing  as  a  subcutaneous  wound.  All  wounds,  irre- 
spective of  the  anatomical  structure  of  the  tissues  involved,  heal  by  the 
production  of  new  material  from  pre-existing  fixed  tissue-cells.  The  fixed 
tissue-cells  at  the  site  of  injury  being  endowed  from  earliest  embryonal 
life  with  a  peculiar  power  of  adaptation  to  existing  conditions  surround- 
ing them,  assume  active  tissue  proliferation,  and  the  embrj'onal  cells  thus 
produced  constitute  the  granulation-tissue,  whicii,  toward  the  completion 
of  the  healing  process,  is  transformed  into  mature  cells,  representing  the 
tissue  or  tissues  which  have  undergone  the  reparative  process. 


IMMEDIATE    OR    DIRECT    UNION.  3 

IMMEDIATE    OR    DIRECT    UNION. 

Since  the  time  of  Jolin  Hunter  a  great  deal  lias  been  said  and 
written  on  immediate  or  direct  union  of  Avounds,  Hunter  believed  that 
this  method  of  healing  would  be  accomplished  within  a  few  hours,  and 
without  the  interposition  of  new  material  between  the  accurately  coapted 
surfaces.  Macartney  was  a  supporter  of  this  view,  as  will  be  seen  fiom 
the  following:  "The  circumstances  under  Avhich  immediate  union  is 
effected  are  the  cases  of  incised  wounds  that  admit  of  being,  with  safety 
and  propriety,  closely  and  immediately  bound  up.  The  blood,  if  any  be 
shed  on  the  surface  of  the  wouiid,  is  thus  pressed  out,  and  the  divided 
blood-vessels  and  nerves  are  brought  into  perfect  contact,  and  union  ma^' 
take  place  in  a  few  hours  ;  and,  as  no  intermediate  substance  exists  in  a 
wound  so  healed,  no  mark  or  cicatrix  is  left  behind."  Paget  applies  this 
method  of  healing  to  large  wounds  where  rapid  union  is  accomplished, 
and  where,  on  examination,  no  interposed  tissue  is  found  between  their 
edges.  Such  a  case  came  under  his  own  observation.  A  patient  on 
whom  he  had  performed  an  operation  for  the  removal  of  a  carcinomatous 
breast  died  from  an  attack  of  erysipelas  a  few  da3-s  later.  Examination 
showed  that  firm  union  had  taken  place  apparently  without  an}-  inter- 
mediate material.  He  also  made  three  experiments  on  raljbits  for  the 
purpose  of  studying  this  rapid  method  of  repair.  The  hair  was  removed, 
the  skin  incised,  and  the  wound  accurateh'  sutured.  Three  days  later  he 
examined  the  parts,  and  found  the  wound  quite  firmly  united,  without 
an}-  macroscopical  evidences  of  inflammation.  On  microscopical  examina- 
tion, he  found  some  exudation  material  in  the  immediate  vicinit}'  of  the 
Avound. 

Among  the  more  modern  investigators,  we  find  Thiersch  still  up- 
holding the  possibility  of  immediate  union  b}-  direct  cohesion  of  similar 
parts.  He  studied  the  repair  of  wounds  in  the  tongue  of  guinea-pigs. 
The  tongue  was  incised  in  a  longitudinal  direction,  and  the  parts  were 
examined  a  few  hours  to  several  days  after  the  injury  had  been  in- 
flicted. Before  sections  were  made  for  microscopical  examination  the 
lingual  vessels  were  injected  with  liquid  glue  stained  with  carmine.  In 
specimens  where  the  wound  was  only  a  few  hours  old  lie  found,  at  least, 
parts  of  the  wound  firmly  adherent,  and  on  microscopical  examination 
he  satisfied  himself  that  the  connective  tissue,  saturated  with  blood  and 
plasma,  had  formed  an  immediate  and  permanent  union.  He  described 
also  a  plasmatic  circulation  in  the  wound  which  he  considered  of  great 
importance  for  the  nutrition  of  the  tissues.  He  believed  that  these  new 
cliaiinels,  by  becoming  paved  with  the  adjacent  connective  cells,  could  be 
transformed  into  permanent  blood-vessels. 

The  same  section  examined  under  a  higher  power  furnishes  a  good 


PRINCIPLES   OF    SURGERY. 


.S'.' 


\ 


illiistnition  of  the  part  taken  by  the  fixed  tissue-cell  in  the  repair  of  the 

wound. 

Some  surgeons  still  believe  in  immediate  union  in  the  repair  of 

wounds  of  nerves,  as  many  cases  have 
been  reported  where  complete  restora- 
tion of  function  was  claimed  to  have 
been  establislied  within  a  few  hours 
after  nerve  suture.  Such  observations 
are  not  free  from  criticism,  because 
functional  results  after  nerve  suture 
maj'  lead  to  wrong  conclusions,  as 
restoration  of  function  in  distal  pa,rts 
may  be  owing  to  tlie  presence  of  other 
nerves  which  reach  such  parts,  and 
partly  it  may  be  due  to  physical  con- 
^  ductio)!  of  irritation.    The  occurrence 


^ 


^^ 


iiW^ 


A.'itU'lSli'ffi^.s. 


'■'■i^ 


Fig.  1.— a  Wound  Twenty-six  Hours  Old.    (Thiersch.) 

A.  Coaptated  parts  apparently  united.  Tissues  only  slightly  stained  with  coloring  material  of  blood  ; 
few  leucocytes.  B.  B.  Spaces  hctween  wound-surfaces  filled  with  red  and  white  blood-corpuscles,  some 
of  the  former  well  preserved,  others  showing  various  degrees  of  disintegration  ;  between  them,  oedema^ 
tons  connective-tissue  fibres.  C,  C  show  that  these  fibres  are  continuous  with  the  connective  tissue  of 
the  wound-surfaces.  Surface  of  wound  coaptation  imperfect ;  the  epithelial  cells  dip  down  into  the 
wound.  D.  A  separated  cone  of  new  tissue.  B.  Infiltration  of  fatty  tissue  with  blood  and  leucocytes. 
G.  Divided  muscular  fibres,  with  escaped  pieces  which  have  partly  undergone  colloid  degeneration. 
(Hartnack,  Obj.  4,  Oc.  2.) 


of  immediate  union  was  doubted  by  O'Halleran,  a  distinguished  contem- 
l)orary  of  Bell,  as  may  be  learned  from  the  following  quotation: 
"  I  would  ask  the  most  ignorant  tNro  in  our  profession  whether  he  ever 
saw,  or  heard  even,  of  a  wound,  though  no  more  than  one  inch  long, 


IMMEDIATE    OR    DIRECT    UNION. 


united  in  so  short  a  time,"  adding,  "  These  tales  are  told  with  more 
confidence  than  veracity  ;  healing  by  inosculation,  by  the  first  intention, 
by  immediate  coalescence  without  suppuration  is  merel}'  chimerical  and 
opposite  to  the  rules  of  nature." 

Gussenbauer  repeated  the  experiments  of  Thiersch  and  Wywodzoff 
on  the  healing  of  wounds  in  the  tongue  of  guinea-pigs,  and  came  to 
entirely  different  conclusions.  In  wounds  eight  to  twelve  hours  old  he 
found  that  the  margins  formed  an  elliptical  space,  the  separation  being 
widest   in    the   middle.     The    divided    muscular    fibres    had    retracted, 


Fig.  2.    (Thiersch.) 

A,  embryonal  cells  showing  karyokinetic  figures;  B,  lymph-spaces;  C,  striped  masses  infiltrated 
with  red  blood-corpuscles  in  various  stages  of  disintegration ;  D,  blood-vessel ;  F,  fat-tissue.  (Hartnack, 
Obj.  8,  Oe.  4.) 

imparting  to  the  wound  an  uneven  surface,  which  was  covered  with  a 
layer  of  reddish,  gelatinous  material.  In  recent  wounds  the  space  is 
filled  with  blood-corpuscles  which  are  often  much  changed  in  color,  size, 
and  shape.  In  wounds  twenty-four  to  forty -eight  hours  old  the  material 
between  the  surfaces  of  the  wound  presented  a  reticulated  appearance,  each 
one  of  the  s[)aces  corresponding  to  a  blood-vessel.  Contrary  to  Thiersch, 
he  asserts  that  in  this  substance  no  connective  tissue  can  be  found  ;  the 
reticulated  structure  he  attributed  to  the  presence  of  fibrin,  the  coagulum 
infiltrating  at  the  same  time  the  adjacent  tissues.     He  believes  that  the 


6  PRINCIPLES   OF    SURGERY. 

p.ireneliymn  fluid  tnkes  part  in  tlie  formation  of  tho  coagulum.  He  was 
unable  to  verify,  by  his  own  observations,  the  existence  of  the  i)lasma 
channels  described  by  Thiersch.  When  the  wound-surfaces  were  kept 
accuratel}'  approximated  he  found  few  blood-corpuscles,  but  the  net-work 
of  fibrin  was  never  found  absent.  In  hare-lip  oi)erations  and  incised 
wounds  of  the  face  and  scalj),  if  uninterru[)ted  apposition  is  maintained 
I'or  a  day  or  two,  the  i)arts  are  found  so  firmly  glued  together  that  the 
belief  that  immediate  union  had  taken  place  might  still  be  maintained 
i'rom  a  superficial  examination,  but  a  microscopical  examination  will 
always  reveal  the  conditions  described  by  Gussenbauer,  and  the  union  is 
therefore  only  apparent,  and  nc^t  real.  The  surfaces  of  the  wound  have 
become  adhei'ent  by  the  interposition  of  an  adhesive  material.  A  certain 
amount  of  coagulation  necrosis  takes  place  in  every  wound,  and  the 
material  thus  formed  serves  as  a  cement-substance  which  temporarily 
glues  the  parts  together.  This  mechanical  union,  the  result  of  destruc- 
tive chemical  changes  in  tlie  extravasated  blood,  is  the  form  of  union 
which  has  been  wrongly  interpreted  and  described  as  immediate  union. 
This  primar}'  adhesion  occurs  most  readily  in  wounds  of  dense  vascular 
tissue  and  where  approximation  and  fixation  of  the  edges  of  the  wound 
are  most  thoroughly  secured, — conditions  which  favor  the  subsequent 
definitive  healing  of  the  wound  by  the  interposition  of  new  tissue. 

UNION    BY    PRIMARY    INTENTION. 

Organic  union,  the  union  aimed  at  in  the  treatment  of  all  wounds, 
is  only  obtained  by  tissue-proliferation  from  the  fixed  cells  of  the  injured 
parts,  and  is  completed  only  after  restoration  of  the  continuity  of  the 
divided  structures,  and  the  return,  partial  or  complete,  of  the  functions 
suspended  ])y  the  injury  or  disease.  Return  of  structure  and  function 
to  an  at  least  approximately  normal  standard  implies  a  return  of  the 
interrupted  circulation  by  the  formation  of  new  blood-vessels;  in  other 
words,  organic  union  cannot  be  said  to  have  taken  place  without  an 
adequate  supply  of  new  blood-vessels  in  the  new  tissue  which  form  a 
capillary  net-work  between  the  divided  blood-vessels.  Such  a  union, 
even  under  the  most  favorable  circumstances,  cannot  be  established  in 
less  than  six  to  eight  days,  and  its  attainment  may  require  weeks  and 
months.  The  next  method  of  repair  described  by  John  Hunter  was 
union  by  adhesive  inflammation.  Absence  of  sui)puration  and  rapid 
union  liave  alwaj^s  been  considered  as  essential  features  of  this  mode  of 
healing,  and  corresponds  to  the  healing  of  wounds  per  primam  inten- 
tionem,  an  expression  which,  for  obvious  reasons,  has  been  retained  in 
modern  literature  to  distinguish  it  from  the  method  of  healing  per 
secundem  infentionem,  where  the  reparative  process  is  often  indefinitel}'' 


UNIOJS    BY    PRIMARY    INTENTION.  7 

delaj-ed  by  suppuration.  All  wounds  which  heal  witliout  suppuration 
heal  by  primary  union,  either  without  or  with  visible  granulation  tissue. 
An  ideal  result  is  obtained  if  the  divided  surface  unites  throughout  and 
the  repair  in  the  depth  of  the  wound  is  accomplished  during  the  same 
time  underneath  the  united  skin  or  mucous  membrane.  If  there  has 
been  a  considerable  loss  of  surface  tissue  and  the  superficial  portion  of 
the  wound  cannot  be  approximated,  or,  if  rapid  healing  at  the  surface  of 
the  wound  fails  to  take  place,  the  wound  heals  slowly  by  the  formation 
of  a  larger  amount  of  granulation  tissue,  and  3-et,  if  suppuration  does 
not  complicate  the  process  it  must  be  said  that  the  wound  has  healed  by 
primary  union.  This  method  of  healiug  was  exceedingly  rare  before 
antiseptic  surgery  was  practiced,  but  since  that  time  it  is  of  frequent 
occurrence.  All  wounds  which  heal  icithout  siqjpuration  heal  without 
inflammation.  All  inflamed  wounds  suppurate;  the  rejjai-ative  process 
is  delayed  until  the  inflammation  has  subsided.  The  proper  modern 
classification  of  wouuds  in  reference  to  the  method  of  repair  consists  in 
a  distinction  between  (1)  aseptic  wounds  and  (2)  infected  wounds. 
Aseptic  wounds — that  zs,  wounds  not  contaminated  icith  pathogenic  micro- 
organisms— heal  without  inflammation.  An  aseptic  wound,  as  a  rule,  is 
painless,  and  does  not  px'esent  ixwy  of  the  other  witnesses  of  inflammation. 
The  slight  swelling  and,  perhaps,  redness  are  the  result  of  mechanical 
disturbances  of  the  circulation,  and  subside  with  the  formation  of  an 
adequate  collateral  circulation  ;  hence,  from  an  etiological  and  pathological 
point  of  view,  we  have  no  legitimate  right  to  apply  the  term  inflanmiation 
to  such  a  method  of  repair.  Koenig  makes  the  statement  that  the 
product  of  tissue-proliferation  in  the  healing  of  an  aseptic  wound  is  not 
in  excess  of  the  local  demand  ;  hence,  the  process  is  purel}'  one  of  regen- 
eration, and  not  inflammation.  Hueter  was  one  of  the  first  who  insisted 
on  limiting  the  meaning  of  the  term  inflammation,  which  he  wished  to 
have  applied  onl^'  to  destructive  processes  caused  by  the  action  of 
specific  microbes.  In  an  aseptic  wound  the  fixed  tissue-cells  assume 
tissue-proliferation,  by  virtue  of  their  intrinsic  vegetative  power,  within 
a  few  hours  after  the  injury  has  been  inflicted,  and  all  the  permanent 
material  utilized  in  the  process  of  repair  is  derived  from  this  source. 
The  leucocytes  serve  a  useful  purpose  in  the  temporary  closure  of 
divided  capillary  vessels  and  in  the  formation  of  the  temporary'  cement- 
substance  by  which  the  surfaces  of  the  wound  are  mechauicall}*  glued 
together,  and,  lastly,  as  food  for  the  embryonal  cells,  but  they  take  no 
active  part  in  the  production  of  neiv  tissue. 

In  studying  the  process  of  healing  in  wounds  as  well  as  in  the  con- 
sideration of  regeneration  in  genei'al,  it  is  of  the  greatest  importance  to 
become  familiar  with  the  histological  changes  which  precede  and  attend 


8 


PRINCIPLES    OF    SUlUiERY. 


the  formation  of  new  tissue;  hence,  in  this  connection  should  be  given  a 
description  of 

KARYOKINESIS. 

Karyolvinesis,  or  karyomitosis,  as  described  by  Flemming,  is  the  in- 
direct reproduction  of  cells  as  compared  with  direct  cell-division  by 
segmentation.  It  is  a  process  by  which  the  net-work  of  chromatin 
tlireads  within  the  nucleus  undergoes  great  development,  and  is  snbject 
to  certain  transformations  of  form,  which  are  instrumental  in  ertecting 
division  of  nucleus  and  cell.  The  term  karyokinesi.s  was  first  used  by 
Schleicher,  and  the  first  accurate  description  of  the  process,  as  seen  in 
the  cells  of  a  number  of  animals,  simple  in  form  and  structure,  was  given 
by  Biitschli  in  18Y6.  The  motlern  definition  of  a  cell  is  much  more  com- 
plicated than  that  given  b}^  Schleiden  and  Schwann,  as  recent  researches 
have  shown  that  it  is  not  such  a  simple   structure  as  it  was   formerly 


Fig.  .3.— Quiescent  Nucleus.  Epithelial 
Cell  of  Salamander  Entering  upon 
THE  "Glomerular"  Phase.  {Flem- 
ming. ) 


Fig.  4.— Living  Cell  of  Salamander. 

(Flemniinff.) 

A,  granules    aggreg.^ted  round  a  pole  of  the  cell ;   B, 

coils  of  "glomerular"  net-work;  C,  cell-body. 


believed  to  be.  When  we  speak  of  a  cell  now  we  mean  a  mass  of  cir- 
cumscribed living  substance,  with  or  without  an  envelope,  which  con- 
tains as  an  essential  element  in  its  interior  a  nucleus,  with  the  property 
of  forming  new  compounds  out  of  substances  taken  into  it,  and  is  capable 
of  reproduction  by  division.  Both  the  nucleus  and  cell  are  composed  of 
threads  and  intermediate  substance.  The  cell-body  consists  of  threads 
somewhat  irregularly  distributed,  seldom  forming  a  net-work,  embedded 
in  a  homogeneous  substance.  The  nuclear  threads  stain  with  liaima- 
toxylon  and  safranin,  and  hence  are  called  chromatin  threads,  Aviiich  are 
arranged  in  a  net-like  figure,  the  meshes  of  which  are  filled  with  a  sub- 
stance which  cannot  be  stained,  and  hence  is  named  by  Flemming 
achromatwe.  The  nucleus  is  surrounded  bj^  a  membrane  composed  of 
two  la3'ers ;  the  inner  can  be  stained,  but  not  the  outer.  The  nucleoli, 
usually  multi])le,  are  made  up  of  a  substance  more  refractile  than  the 
structures  described   in   the  nucleus.     They  are  round  and  smooth,  and 


KARTOKINESIS.  9 

either  suspended  in  the  not-work  or  between  tlie  tlireads.  The  nucleus 
in  a  cell  that  is  not  in  a  condition  ol"  functional  activit}'  is  said  to  be  in 
a  quiescent  or  resting  state. 

At  this  time  the  chromatin  threads  become  transformed  into  a  sort 
of  skein,  formed  apparently  of  one  long,  convoluted  thread  ;  the  inner 
layer  of  the  nuclear  membrane  and  nucleoli  disappear,  or  are  incorporated 
into  the  achromatine  substance  of  the  nucleus.  The  development  of  the 
net-work  of  the  chromatin  substance  in  the  nucleus  undergoes  five  phases 
until  complete  division  of  the  nucleus  and  cell  has  been  eflected. 

Phase  I,  The  first  change  indicative  of  beginning  karyokinesis, 
according  to  Flemming,  is  the  formation  within  the  cell-protoplasm  of 
two  poles  opposite  to  each  other  and  near  the  nucleus. 

The  next   change  noticed   is  that  in  the  nucleus :   the   chromatin 


Fig.  5.— Endothelial  CEiii-S;  Abdomen  of  Salamander.    (Flemming.) 

1.  Surface  view  of  nuclear  net-work:  A,  cell-body;  B.  threads  of  net-work;  C,  one  of  the  poles 
with  the  achromatine  threads  radiating  from  it.  2.  Equatorial  view  of  a  corresponding  cell;  A,  one  of 
the  poles;  B,  the  nuclear  net-work  seen  on  edge;  C,  the  achromatine  threads  forming  a  spindle 
beween  the  poles. 

threads  become  plainer,  thicker,  and  more  convoluted.  This  increase  of 
chromatin  substance  is  the  result  of  longitudinal  splitting  of  its  threads. 
The  achromatine  layer  of  the  nuclear  envelope  increases  in  thickness, 
while  the  inner  layer  has  become  a  part  of  the  chromatin  net-work. 

Phase  II.  During  tiiis  stage  the  chromatin  threads  are  drawn  out 
into  loops  with  long  limbs.  This  arrangement  imi)arts  to  tlie  hxijied 
net-work  the  figure  of  an  aster,  or  star. 

In  the  middle  of  the  star  is  a  clear  space,  which  does  not  stain  and 
is  occupied  by  achromatine  substance.  In  animal  cells  the  greater  portion 
of  the  space  within  the  nuclear  membrane  is  tilled  with  cliromatin  threads, 
while  in  vegetable  cells  the  achromatine  substance  predominates.  The 
nuclear  spindle  in  the  centre  of  the  achromatine  substance  (Fig.  4,  C), 
according  to  Strassburger  and  Biitschli,  consists  of  fine,  colorless  fibres, 


10 


PRINCIPLES   OF    SURGERY. 


which  do  not  stain  at  all,  or  only  slightly,  l)y  using  special  nucleus- 
staining  reagents,  and  on  this  account  the  achromatine  threads  probably 
contain  no  nuclein. 

Phase  III.  The  star-shaped  mass  of  nuclear  threads  divides  into 
two  equal  portions,  with  the  angles  of  the  loops  to  the  poles,  and  their 
limbs  partly  obliquely,  partly  perpendicularlj-  to  the  equator  of  the 
nucleus. 

The  equatorial  disk  is  formed  in  this  manner,  and  indicates  the 
completion  of  this  phase. 

Phase  IV.  This  phase  begins  with  a  separation  of  the  threads  at  the 
equator,  and  ends  with  concentration  of  the  threads  in  each  polar  segment 
of  the  cell. 

As  the  number  of  loops  in  each  segment  is  the  same  as  in  the  old 


Fig.  6.— Epithelial  Cell  of  Salamander. 

(Flemming.) 
A,  pole  and  achromatine  threads;   B,  cell-body  ;   C,  disk- 
like arrangement  of  chromatin  threads  at  equator  of  nucleus. 


Fig.  7.— Epithelial  Cell  of  Sala- 
mander.    (Flemming.) 

A,  A',   chromatin  threads  of  daughter-stars; 
B,  achromatine  threads  and  pole. 


nucleus,  it  may  be  conjectured  that  the  halves  of  each  thread  separate 
into  the  two  daughter-stars. 

Phase  V.  The  threads  in  the  daughter-nucleus  form  a  wreath,  after 
which  they  contract  more  and  more  until  the  undivided  convolutions  can 
hardly  be  recognized. 

A  nuclear  membrane  again  appears,  after  which  the  net-work  returns 
to  its  quiescent  state. 

There  is  a  strong  tendency  at  the  present  time  to  refer  all  karyo- 
i^inetic  changes  to  the  agency  of  the  nucleus,  and  to  ascribe  to  the  proto- 
plasm of  the  cell  the  passive  role  of  a  nutritive  substance.  In  the 
imiiregnated  ovum  the  influence  of  nuclear  changes  has  been  described, 
but  at  the  same  time  it  was  shown  that  the  protoplasm  of  the  cell  is 
callable  of  automatic  as  well  as  responsive  action.  Pfliiger  asserted  that 
gravitation  is  the  sole  guiding  agency  in  the  process  of  cleavage  of 
protoplasm.     According  to  Born,  Herturg,  Weismann.  and  Kolliker,  the 


KARTOKINESIS. 


11 


protoplasm  alone  is  isotropic,  but  Whitman  thinks  that  this  is  far  from 
the  truth.  Others,  lilve  Pfliiger,  believe  that  the  protoplasm  contains 
physiological  molecules  from  which  organs  are  developed.  Polaritv 
of  cell-protoplasm  and  in  nucleus  exists  independenth',  and  is  not  recip- 
rocal. Contractions  in  nn fertilized  ova  have  been  observed.  M.  Xuss- 
baum  was  the  first  to  prove  that  enucleate  fragments  of  an  infusorium 
are  incapable  of  reproduction,  while  parts  of  an  infusorium  containing  a 
nucleus  possessed  this  power.  This  would  tend  to  establish  the  fact  that 
the  nucleus  is  indispensable  to  the  preservation  of  the  vegetative  energy 
of  the  cell.  On  the  other  hand, 
Gruber,  in  one  of  his  experiments, 
divided  a  stentor  before  fission  had 
taken  place  in  such  a  mnnner  that 
the  sections  contained  no  nuclenr 
substance,  and  3'et  the  next  day  each 
one  of  these  parts  represented  a 
complete  stentor.  Against  the  con- 
clusions drawn  from  this  experiment 
it  might  be  urged  that  some  of  the 
nuclear  chromatin  threads  might 
have  found  their  way  into  the  cell- 
protoplasm  ,  and  that  from  them  the 
process  of  reproduction  started. 
Nussbaum  regards  a  combination 
of  nuclear  structure  and  eell-proto-  li/:^ 
plasm  as  essential  for  cell-produc- 
tion. According  to  Flemming,  the 
cell-body  begins  to  divide  toward 
the  end  of  the  fourth  phase  of  karyo- 
kinesis.  Cell-division  commences 
with  a  constriction  at  the  equator, 
which  becomes  deeper  and  deeper  as 
the  daughter-cells  assume  cell  form, 

until  complete  regeneration  takes  place.  Toward  the  completion  of  the 
separation  onl}'  a  few  achromatine  threads  (Fig.  8,  B)  connect  the  two. 
To  Flemming  belongs  the  credit  of  having  first  discovered  karyokinetic 
changes  in  cells  undergoing  division,  but  our  knowledge  of  this  subject 
has  been  greatly  advanced  by  the  combined  labors  of  Strassburger, 
Arnold,  Klebs,  and  Whitman.  Arnold  studied  this  method  of  cell- 
division  in  giant  cells  of  the  medulla  and  in  the  blood-corpuscles  of 
leuksemic  blood.  He  preserved  the  blood-corpuscles  in  a  6-per-cent. 
methyl-green  salt-solution,  which  preserves  cells  in  a  good  condition  if 


Fig.  8.— Epithelial  Cell  of  Salaman- 
der.    (Flemming.) 

A,  A',  daiighter-glomeruH  ;  B,  achromatine  threads  still 
uniting  tlie  two  daughter-cells. 


\2  PRINCIPLES    OF    SURGF:riV. 

the  solution  is  kept  at  a  iJiopcr  tcniperature  in  the  moist  chaml)er  on  the 
o])ject-u,hiss.  If  to  tills  solution  a  25-per-cent.  solution  of  chloride  of 
U'old  is  added,  the  karyokinetic  figures  are  made  clearer.  In  studying 
the  process  of  karyokinesis  in  fixed  tissue-cells  in  a  state  of  infiltration, 
it  is  necessary  to  resort  to  the  fixation  and  staining  methods  described 
by  Flemming.  The  modern  observers  who  have  studied  regeneration  of 
epithelial  cells  have  come  to  the  conclusion  that  cell-division  takes  place 
almost  exclusively  by  karyokinesis.  Podwyssozki  has  studied  this 
method  of  cell-reproduction  with  special  reference  to  regeneration  of 
liver-cells,  and  has  come  to  some  ver}'  important  conclusions.  In  cats 
and  young  guinea-pigs  he  observed,  after  injurj'  of  the  liver,  extra-nuclear 
chromatin  substance  before  he  could  detect  any  karyokinetic  figures 
in  the  nucleus.  The  chromatin  in  the  cell-body  appeared  in  two  forms,- — 
either  as  fine  granules  scattered  diffusely  through  the  protoplasm  of  the 
cell,  or  a,s  lumps  of  chromatin,  and  he  designated  these  larger  masses  as 
procliromatin  ;  but  he  also  noticed  that  the  granular  form,  at  a  later  stage, 
aggregated  and  formed  masses  which  united  with  the  nuclear  chromatin. 
Klebs  explains  the  presence  of  chromatin  in  the  cell-protoplasm  to  an 
extra-cellular  origin, — the  leucocytes.  He  believes  that  the  chromatin 
contained  in  leucocytes  is  liberated  after  fragmentation  has  taken  place 
and  enters  the  3'oung  cells,  where  they  serve  as  food  and  become  a  part 
of  the  nuclear  net-work.  This  view  is  strengthened  by  the  statement  of 
Podwyssozki  tiiat  he  found  numerous  leucoC3'tes  in  the  immediate  vicinity 
of  the  new  cells.  Ziegler  and  Obolensk}' produced  arsenical  intoxication 
in  animals  l)y  administering  in  daily  doses  subcutaneously,  and  when 
they  examined  the  liver  they  found  well-marked  karyokinetic  figures  in 
the  endothelial  cells  of  the  intra-acinous  capillaries,  the  epithelia  of  the 
bile-ducts,  and,  less  frequently,  in  the  secreting  cells.  Karyokinetic 
figures  were  first  visible  in  the  nuclei  of  the  capilhuy  endothelia,  and 
Avere  undoubtedl3'  caused  by  the  direct  action  of  the  arsenic  upon  the 
cells.  These  experiments  show  that  karyokinesis  will  follow  the  applica- 
tion of  chemical  as  well  as  traumatic  irritants. 

FRAGMENTATION  OF  NUCLEUS 
Arnold  and  Pfitzner  have  described,  in  giant  and  other  cells  under- 
going pathological  changes,  direct  fragmentary  division  of  the  nucleus, 
by  which  it  may  break  up  into  many  parts,  often  of  unequal  size,  without 
contemporaneous  division  of  the  cell.  Arnold  and  others  have  also  de- 
scribed incomplete  fragmentation  of  the  nucleus  where  the  nuclear  masses 
remain  connected  with  each  other,  and  can  be  seen  as  lobulated  and 
reticulated  structures.  Arnold  saw  fragmentation  of  the  nucleus  in  the 
cells  of  the  marrow  of  bone  and  in  leucocytes  undergoing  transformation 


DIRECT    CEI.L-DlVrSTOX.  13 

into  piis-corpuscles.  A  nucleus  which  undergoes  fragmentation  contains 
but  little  chromatin  substance,  and  is  therefore  incapable  of  multiplica- 
tion by  kar^'okinesis  ;  and  such  cells,  according  to  the  investigations  of 
Klebs,  never  take  an  active  part  in  the  regeneration  of  tissue. 

DIRECT    CELL-DIVISION. 

In  1841  Martin  Barry  first  made  the  observation  that  the  division 
of  cells  was  accompanied  with  division  of  the  nucleus,  and  for  a  long- 
time it  was  believed  that  tiiis  process  is  simply  a  segmentation  of  the 
nucleus,  followed  bv  division  of  the  whole  cell.  Remak  taught  that 
direct  division  commenced  in  the  nucleolus,  extended  to  the  nucleus,  and 
finally  resulted  in  fission  of  the  cell-body,  each  of  the  new  cells  contain- 
ing a  daughter-nucleus. 

According  to  Pfitzner,  direct  cell-division  is  a  more  frequent  method 
of  cell-multiplication  than  the  indirect  in  3'oung  animals  where  cell- 
proliferation  is  rapid.  In  the  embryo  the  nucleus  contains  but  little 
chromatin,  and  therefore  the  karyokinetic  figures  are  less  abundant. 


D 


Fig.  9.     (McKendrick.) 


A,  mature  cell :  B,  commencing  division  of  nucle>is  and  contraction  of  cell-protoplasm  in  the  centre  ; 
C,  complete  division  of  nucleus  and  cell;  D,  formation  of  two  new  cells. 

In  most  of  the  regenerntive  processes  in  mature  tissue-cells  repro- 
duction takes  place  by  karvokinesis,  and  only  in  exceptional  instances 
by  direct  division.  The  new  cellular  elements  present  karyokinetic 
figures  in  all  stages,  and  u-herever  these  are  seen  it  is  a  positive  evidence 
that  the  fi.red  tissue-cells  are  the  seat  of  tissue-proliferation^  and  that 
wounds  are  healed  and  defects  repaired  exclusively  hy  this  method  of 
cell-formation . 

GRANULATION  TISSUE. 

The  new  cells  formed  by  indirect  or  direct  cell-division  in  a  wounded 
or  injured  part,  the  seat  of  regenerative  processes,  constitute  the  granu- 
lation tissue  as  long  as  they  remain  in  their  embryonal  state.  As  imme- 
diate union  never  takes  place  in  an}'  part  or  tissue  of  the  body,  we  are 
forced  to  admit  that  every  wound  heals  onlj^b^-  the  interposition  between 
the  divided  parts  of  a  greater  or  less  amount  of  granulation  tissue.  If 
the  wound  remain  aseptic,  and  the  surfaces  of  the  wound  are  kept  in 
accunite  coaptation,  the  healing  is  accomplished  in  a  short  time,  and  b\- 


14 


I'KINCIPLES    OF    SURGERY. 


tlie  prodiietioii  of  a  miiiiinuin  :iiiioiiiit  of  lu'W  tissue.  A  similar  wound, 
witii  grt'ut  loss  of  tissue  prec-luding  the  possibility  of  bringing  the  parts 
in  api)osition  by  mechanical  resources,  nuist  necessarily  heal  by  the  pro- 
duction of  a  large  quantity  of  granulation  tissue,  the  process  of  repair 
in  both  instances  J)eing  the  same,  the  difference  being  mainly  the  length 
of  time  required  to  comj)lete  the  healing  process  and  the  amount  of  new 
material  necessary  for  this  purpose.  In  the  first  c.ise  the  wound  heals 
witliout  visible  granulation  tissue  ;  in  the  latf  er  the  defect  becomes  cov- 
ered with  granulations  before  the  wound  can  heal.  The  macroscopical 
and  microscopical  ni)pearances  of  granulating  surfaces  nre  nearly  iden- 


-^  vr  "%  i;^-^!  ^  1  f^m  n£'  v^- 


Fig.  10.— Granulating  Wound.     Capillary   Loops   Surrounded  by 
Embryonal  Cells,    x  300-400.    (Billroth- Winiwarter.) 

tical  in  all  the  tissues.  A  bone  covered  with  granulations  looks  the  same 
as  a  granulating  surface  of  any  of  the  soft  tissues.  Even  the  embryonal 
cells  of  which  tlie  granulations  are  covered,  so  long  as  they  remain  in 
this  state,  furnish,  from  their  microscopical  appearances,  only  remote  or 
no  indications  as  to  their  histogenetic  source  and  ultimate  destination. 
Differentiation  takes  place  during  their  further  development  toward  the 
completion  of  the  healing  process.  The  l)ulk  of  all  granulation  tissue  is 
derived  from  the  connective  tissue  as  this  mesoblastic  structure  is  dif- 
fused throughout  the  entire  bod}^  and,  with  the  exception  of  the  nervous 
system,  is  found   in  almost  every  organ.     In  the  nervous  sjstem   it  is 


GRANULATION    TISSUE. 


15 


represented  In-  an  almost  similar  tissne, — the  neuroglia, — which  performs 
the  same  role  in  the  repair  of  injuries  and  defects  of  the  brain,  spinal 
cord,  and  nerves.  A  ■wound  or  defect  covered  with  granulations  presents 
a  velvet}'  appearance,  each  tuft  or  papilla  representing  a  separate  loop  or 
net-work  of  new  capillar}'  vessels. 

The  new  capillary  vessels  are  paved  with  endothelial  cells  contain- 


FiG.  11.— Gra>'Ulation  Tissue  fiuim  Wound.    Blood-vessels  Injected.    X  400. 

(IIamiUo7i.) 

A,  A,  capillary  loops  with  several  branches  ;   B.  ordinary  granulation  cells ;  C,  fibroblasts;  D,  stroma. 

ing  a  very  large  nucleus.  Sometimes  a  single  capillary  vessel  enters  a 
papilla  and  gives  off  a  number  of  branches,  which  form  a  net-work  of 
convoluted  vessels,  rendering  the  granulations  exceedingl}'  vascular  and 
liable  to  bleed  on  the  slightest  provocation. 

The  blood  in  the  tuft  is  collected  and  returned  usually  through  one 
vein.  Emigi'ation  of  leucocytes  through  the  walls  of  the  new  capillary 
vessels  is  a  common  occurrence,  and,  when  they  reach  the  surface,  form 


16  PRINCIPLES    OF    SURGERY. 

one  of  the  elements  of  secretion  of  the  wound.  Wlien  the  cap''lary 
vessels  are  imperfectly  developed,  or  when  they  are  in  a  state  of  in- 
flammation, the  exudation  becomes  profuse,  and  the  granulation  surface 
becomes  covered  with  a  membrane  consisting  of  the  products  of  coagula- 
tion necrosis.  Wounds  presenting  such  an  appearance  have  frequently 
been  mistaken  as  an  evidence  of  diphtheritic  infection.  The  so-called 
healthy  granulations  are  small,  firm,  and  of  a  pinkish-red  color,  and 
such  a  surface  is  only  moistened  with  colorless,  viscid  fluid.  Wounds 
covered  with  such  granulations  heal  rapidly  and  leave  a  small,  pliable 
cicatrix.  Profuse  flabby  and  pale  granulations  indicate  a  want  of  general 
vitality,  or  more  frequently  the  presence  of  specific  microbes,  wliich  act 
injuriously  upon  the  process  of  transition  of  embryonal  cells  into  tissue 
of  a  higher  tj'pe.  Such  granulations  are  frecjuently  met  with  in  wounds 
after  im[)erfect  operations  for  tubercular  lesions,  in  suppurating  wounds, 
and  in  ulcers  of  the  lower  extremities,  where  the  vascular  conditions  are 
unfavorable  for  the  growth  and  development  of  new  tissue.  Histologi- 
call}^  granulation  tissue  is  composed  of  a  delicate,  oedematous  reticulum, 
and  upon  its  fibres  can  be  seen  numerous  connective-tissue  corpuscles. 
The  reticulum  is  intimately  connected  with  the  blood-vessels,  and  in  its 
meshes  are  contained  the  embryonal  cells  and  leucocytes,  the  latter 
serving  as  food  for  the  former.  The  embryonal  connective-tissue  cells 
are  about  two  or  three  times  larger  than  the  leucocytes.  The  giant  cells 
which  are  occasionally  found  are  fibroblasts  wliich  have  grown  to  such 
enormous  proportions  by  inclusion  of  nutritive  material  derived  from 
disintegrating  leucocytes. 

VASCULARIZATION    OF    GRANULATION    TISSUE. 

The  vessels  which  furnish  the  blood  supph'  to  the  granulation 
tissue  are  new  structures,  and  are  usually  formed  from  pre-existing 
vessels  in  injured  vascular  tissue,  and  from  the  nearest  blood-vessels  in 
non-vascular  tissue.  Vessel  formation  and  tissue  proliferation  are 
initiated  simultaneously,  and  keep  pace  with  each  other  until  the  neces- 
sary amount  of  granulation  tissue  has  been  produced,  when,  during  the 
transformation  of  the  embryonal  cells  into  pernument  tissue,  the  vascular 
supply  is  gradually  diminished  by  the  obliteration  and  disappearance  of 
all  of  the  superfluous  vessels.  As  the  layer  of  granulation  tissue  seldom 
exceeds  more  than  ^  inch  in  thickness,  the  new  A^essels  always  remain 
short,  and  retain  their  communication  with  the  pre-existing  vessels  from 
which  they  started.  TraA^ers,  in  his  experiments  on  injuries  of  the  frog's 
web,  has  observed  that  the  blood  in  the  divided  vessels  becomes  stagnant 
some  little  distance  from  the  wound.  During  this  time  material  oozes 
from  the  cut   vessels,  which   constitutes   the   primary-wound   secretion. 


VASCULARIZATION    OF    GRANULATION   TISSUE. 


17 


Befc^e    granulations    can   be  established  the  circulation    must   become 
restored  by  enlargement  and  multiplication  of  preformed  vessels. 

The  capillar}'  vessels  which  have  been  cut  or  otherwise  injured  are 
closed  with  nature's  htemostatic — a  minute  thrombus.  The  intra-vascular 
pressure  on  the  proximal  side  of  the  obstruction  results  in  dilatation  of 
the  vessel,  which  produces  an  increased  blood-supply  to  the  part  com- 
mensurate with  the  increased  demand  for  nutritive  material.  The  new 
blood-vessels  are  formed  by  angioblasts,  which  are  proliferated  from  pre- 
existing vascular  structures.  Arnold  has  studied  the  formation  of  new 
blood-vessels  in  the  stump  of  the  tail  of  tadpoles  after  amputation,  and 


Fig.  12.— Superficial  Capillaries  op  a  Wound  Beginning  to  Granulate,  about 
Forty-eight  Holrs  after  its  Infliction.    X  350.    {Hamilton.) 

^,  free  surface  ;   B,  tlie  capillary  loops  all  distended  with  blood,  and  being  driven  outward  in  tortuous 
festoons  ;  C,  embryonal  cells. 


in  keratitis  vasculosa  artificiall}^  produced  in  the  cornea  of  rabbits.  To 
the  researches  of  this  author  we  owe  most  of  the  knowledge  we  possess 
on  this  subject.  The  new  vessels  are  produced  by  the  budding  process 
from  capillaries  near  the  surface  of  the  wound.  The  bud  appears  first 
as  a  circumscribed  thickening  of  the  capillary  wall,  which  soon  projects 
outward  in  the  form  of  a  triangular  cellular  mass  composed  of  angio- 
blasts. The  bud  is  then  transformed  into  a  long  string,  terminating  in 
a  delicate  granular  thread. 

The  base  of  such  a  projection  becomes  excavated,  and  blood  enters 
from  the  vessel  to  which  it  is  attached.     When  the  terminal  ends  of  two 

2 


18  PRINCIPLES   OF   SURGERY. 

of  such  projections  meet  they  unite  and  form  an  arch,  which,  after  they 
have  become  permeal)le  to  the  blood-current,  constitute  a  capillary  loop 
from  which  branches  again  may  develop  in  the  same  manner.  The  new 
channels  contain,  upon  their  inner  surfaces,  nuclei  at  variable  distances, 
which  subsequently  undergo  transformation  into  endothelial  cells.  The 
adventitia  is  formed  b}'  roimd  cells,  which  arrange  themselves  along  the 
outer  surface  of  the  new  channels.  Hunter  maintained  that  blood- 
vessels are  formed  in  granulations  independently^  of  pre-existing  vessels, 
in  the  same  manner  as  in  the  embryo,  and  that  they  enter  into  commu- 
nication with  the  vascular  s^-stem  subsequently.  Such  a  method  of 
vascularization  during  post-embryonie  life  is  not  jjroved.  A  number  of 
pathologists,  and  among  them  Billroth,  still  believe  that  blood-corpuscles 
and  blood-vessels  can  be  produced  from  connective  tissue.  Thej'  claim 
that  connective-tissue  cells  in  the  intercapillarj'^  spaces  enlarge,  become 
branched,  and  that  by  union  between  similar  projections  between  two  or 


Fig.  13.— Formation  of  New  Blood-vessels  by  Budding.    {Arnold.) 

A,  after  three  hours ;  B,  after  six  hours. 

more  cells  hollow  spaces  are  created  which  serve  as  blood-vessels,  while 
the  nucleus  assumes  the  role  of  a  hgemapoietic  organ, — a  process  which  is 
well  illustrated  by  Fig.  14. 

Still  another  method  of  vessel  formation  in  granulations  has  been 
observed  and  described  by  Travers.  He  noticed  that,  when  one  of  the 
new  capillary  vessels  ruptures  and  blood  is  poured  out  into  the  granula- 
tion tissue,  among  the  embr3'onal  cells  a  vascular  space  without  walls  is 
formed.  The  extravasated  blood,  under  these  circumstances,  did  not 
disintegrate,  and  as  soon  as  the  space  came  in  contact  with  another 
capillary  loop  the  wall  gave  way  and  a  communication  was  established 
between  the  two  capillary  vessels,  and  later  the  channel  became  lined 
with  endothelial  cells.  Tliis  method  of  vessel  formation  is  termed 
canalization.  While  the  possibility  of  the  development  of  new  vessels 
independently  of  preformed  blood-vessels  cannot  be  denied,  such  an 
origin  is,  to  say  the  least,  exceedingly  rare,  and  for  all  practical  purposes, 


CICATRIZATION. 


19 


b 


when  we  speak  of  vascularization  of  granulation  tissue  or  the  formation 
of  new  blood-vessels  in  general,  we  mean  the  formation  of  new  channels 
b}'  tissue  proliferation  from  the  walls  of  pre-existijig  blood-vessels. 
Dr.  J.  Hamilton,  author  of  the  excellent  "  Text-Book  of  Pathology," 
asserts  that  the  blood-vessels  in  granulation  tissue  are  not  new,  but 
dilated,  tortuous,  preformed  vessels. 

In  wounds  that  heal  rapidly  the  existence  of  most  of  the  new  blood- 
vessels is  a  short  one.  With  the  beginning  of  cicatrization  they 
disappear  rapidly',  and  comparatively 
onl}"^  a  few  of  them  remain  as  per- 
manent structures  as  a  system  of 
collateral  vessels  which  restore  indi- 
rectly the  loss  of  continuit}'  between 
the  divided  vessels.  A  failure  of  the 
vessels  to  disappear  after  cicatrization 
has  been  completed  usuall}'  is  an  indi- 
cation that  some  pathogenic  micro- 
organisms have  become  embedded  in 
the  scar-tissue,  which  interfere  with 
the  proper  and  prompt  transformation 
of  embryonal  into  permanent  tissue. 
Such  scars  are  often  met  with  after 
operations  for  tubercular  lesions  and 
after  the  healing  of  extensive  burns, 
being  caused  in  the  first  instance  by 
the  bacillus  of  tuberculosis  and  in  the 
latter  by  pus-microbes.  The  vascular 
conditions  in  granulating  surfaces 
should  be  carefully  studied,  and  in 
the  treatment  due  attention  should 
be  given  to  this  important  point,  as 
compression  and  position  are  potent 
measures  in  improving  a  fault}^  circulation,  which  maj'^  have  indefinitely 
retarded  the  healing  process. 


Fig.  14.— Development  of  Blood- 
corpuscles  IN  Connective-tissue 
Cells,  and  Transformation  of  the 
Latter  into  Capillary  Blood-ves- 
sels.    (Fluegge.) 

A,  an  elongated  cell  with  a  cavity  in  its  protoplasm 
occupied  by  fluid  and  by  blood-corpuscles;  B,  a  hollow 
cell,  the  nucleus  of  which  has  been  multiplied:  the  new 
nuclei  are  arranged  around  the  wall  of  the  cavity,  the 
corpuscles  in  which  have  now  become  discoid ;  C,  shows 
the  mode  of  union  of  a  "  liannapoietic  "  cell,  which,  in 
this  instance,  contains  only  one  corpuscle,  with  the 
prolongation  (BL)  of  a  previously  existing  vessel. 
A,  and  C,  from  the  newborn  rat ;  B,  from  foetal  sheep. 


CICATRIZATION. 

The  process  of  transformation  of  the  embrj'onal  cells  in  granulation 
tissue  into  permanent,  fixed  tissue-cells  is  called  cicatrization.  Sir  James 
Paget  has  well  said  that  during  the  stage  of  the  healing  process  a  life  of 
eminence  is  changed  into  one  of  longevity.  In  tissues  endowed  with 
great  vegetative  powers  and  a  high  degree  of  adaptation,  even  large 
defects  are  replaced  by  tissue  which  resembles  to  perfection,  anatomi- 


•20 


PRINCIPLES   OF   SURGERY. 


cally,  histologically,  and  physiologically,  the  injured  pre-existing  tissue. 
This  is  the  cLe  in  injuries  involving  considerable  loss  of  substance  m 


■g'C 


|1 

fQ"'S. 


§     2a 


o   ^5 


J3     . 

"a 

a  . 


a  > 


§•2 

J2      - 

•3Q 

ill 

0  q  9 

^  o  m 
.d-s  c 


^-5  8 


bone     tendons,    and    peripl.eral    nerves.     Complete    restoration  of   a 
p:riV.a>  ne"ve  frejntly  takes  place  after  resection  of  more  than  an 


CICATRIZATION. 


21 


inch  of  its  contiuuity.  In  subcutaneous  tenotom}'  the  tendon-ends  may 
be  kept  separated  for  two  or  more  inches,  and  yet  after  a  few  months  it 
would  be  difficult  to  ascertain,  even  after  the  most  careful  examination, 
the  site  of  operation.  The  fractured  ends  of  a  broken  bone  may  be 
complete!}'  separated  by  lateral  displacement  during  the  entire  time 
required  in  the  healing  process,  and  3et  they  are  firml}^  united  b}'  the 
interposition  of  a  connecting  bridge  of  new  bone.  In  other  tissues 
endowed  with  less  reparative  energy,  as  for  instance  the  muscular  fibre, 
a  slight  separation  results  in  the  formation  of  cicatricial  tissue  between 
the  anatomical  structure  Avhich  it  is  the  intention  to  unite.  By  cicatri- 
zation is  therefore  understood  tlie  completion  of  the  reparative  process, 
and  the  term  does  not  necessarily  imply  the  formation  of  a  permanent 
cicatrix.  An  ideal  healing  culminates 
in  the  formation  of  tissue  which  effects 
a  plu'siologicnl  restitution  of  a  defect 
caused  by  injury  or  disease.  As  a  rule, 
it  can  be  stated  that  the  result  will 
be  satisfactory  in  proportion  to  the 
amount  of  granulation  tissue  produced 
or  required  in  the  process  of  repair. 
In  an  aseptic  wound  the  reparative 
material  will  not  be  in  excess  of  tlie 
local  demand,  and  the  demand  will 
depend  on  the  degree  of  accurac}^  of 
approximation  of  the  surfaces  of  the 
wound.  Cicatrization  begins  in  the 
ganulation  tissue  nearest  the  pre- 
formed vessels  ;  that  is,  the  margins 
and  surface  of  the  wound. 

The  embryonal  connective-tissue  cells,  or  fibroblasts,  as  they  are 
cnlled,  at  first  round,  become  elongated  with  thread-like  prolongations 
from  the  extremities. 

The  new  connective  tissue  contracts,  thus  bringing  the  margins  of 
the  wound  or  granulating  surface  in  closer  apposition,  and  by  its 
constricting  effect  assisting  in  the  obliteration  of  superfluous  vessels. 
The  cicatrix  or  scar  will  be  large  if  the  process  of  granulation  has  been 
in  excess  of  the  demand,  or  if  a  large  defect  had  to  be  healed  by  the 
deposition  or  interposition  of  a  large  quantit}'  of  cicatricial  material. 
Large  scnrs  should  be  prevented,  if  possible,  b}'  appropriate  treatment, 
as  from  the  contraction  they  give  rise  to  distressing  deformities,  and 
from  tlieir  low  vitality  they  furnish  a  permanent  predisposition  to  ulcer- 
ative   processes   and   not   infrequently   become   the  seat    of  malignant 


Fig.  16.— Embryonal  Connkctive- 
TissuE  Cell  Undergoing  Transfor- 
mation INTO  r^lATURE  State.    (Ziegler.) 

A,  the  cell-body :  still  contains  a  considerable 
amount  of  protoplasm,  which,  however,  gradually  di- 
minishes toward  D.  where  it  represents  a  mature 
connective-tissue  cell  with  a  very  small  amount  of 
protoplasm  surrounded  by  connective-tissue  fibres. 


22  PRINCIPLES   or   SURGERY. 

disease.  After  the  healing  of  any  ulcer  of  considerable  size  upon  the 
mucous  surface  of  any  of  the  hollow  viscera  the  cicatricial  contraction 
often  gives  rise  to  the  formation  of  strictures.  Nerves  appear  to  form 
in  granulations,  as  these  are  often  exceedingly  tender  to  the  touch. 
Their  existence,  however,  has  not  been  demonstrated.  The  pain  and 
tenderness  ma}'  be  caused  b}'  force  being  transmitted  to  subjacent  nerves. 
According  to  Vanderkolk,  no  I3  mphatic  vessels  are  present  in  granula- 
tion tissue.  During  the  process  of  cicatrization  all  the  embrjonal  cell- 
elements  undergo  transformation  into  mature  tissue,  the  fibroblasts  are 
converted  into  connective  tissue,  the  angioblasts  into  vessels,  the 
mj'oblasts  into  muscle-fibres,  the  osteoblasts  into  bone,  etc.,  each  histo- 
logical  element   represented    in   the    wound   or   defect   furnishing   the 

material  for  its  own  repair. 


EPIDERMIZATION. 

A  wound  of  the  external  sur- 
face of  the  body  can  be  said  to  have 
healed  after  the  completion  of  epi- 
dermization.  In  accordance  with 
the  general  law  of  succession  of 
cells,  epidermization  takes  place  ex- 
clusively by  proliferation  of  pre- 
formed epithelial  cells.  The  new 
epithelial  cells  have  a  more  or  less 
rounded  shape,  and  cover  the  granu- 
lations from  the  margins  of  the 
wound,  where  the  new  skin  appears 
^'''•''■-^'''^^^ff^^a''7KilbI:l'"'' ''"'''''''    as  a  bluish-pink  pellicle.     At  first 

A,  old  epithelial  cells  upon  edge  of  wound  of  skin,  with     thcV    do    UOt    readily    adhere    tO    tllC 
proliferation  of  nucleus.  ''  ^ 

granulations,  but  appear  to  cover 
them  (Fig.  15,  E')  ;  later,  however,  the}'  throw  down  long  processes  which 
penetrate  the  granulations,  and  in  this  way  obtain  a  permanent  foothold. 
New  epithelial  cells  possess  amoeboid  movements,  may  become  detached 
from  the  epithelial  matrix,  and  wander  some  distance  and  form  perma- 
nent attachments,  and  in  such  an  event  an  independent  centre  of  epider- 
mization is  established.  Migration  of  epithelial  cells  was  first  observed 
and  described  by  Klebs  in  superficial  wounds  in  the  skin  of  tlie  frog. 

The  irregular  projections  of  the  new  skin  over  the  granulations,  so 
frequently  observed  during  the  healing  of  wounds  by  granulation,  is 
undoubtedly  often  due  to  such  a  displacement  of  embryonal  epithelial 
cells.  In  granulating  surfaces  following  destruction  of  the  skin  by  burns, 
caustics,  or  ulceration,  independent  centres  of  epidermization  are  often 


POSITIVE   INDICATIONS   IN   THE   TREATMENT   OF   WOUNDS.         2o 

seen  in  the  midst  of  the  field  of  granulations.  In  sucli  cases  the  entire 
thickness  of  the  skin  at  some  points  has  not  been  destroyed,  and  epi- 
thelial proliferation  takes  place  from  remaining  remnants  of  glands,  as 
is  well  shown  at  F  and  G  in  Fig.  15.  The  granulations  in  the  immediate 
vicinity  of  the  zone  of  epidermization  become  reduced  in  size,  the  blood- 
vessels are  diminished  in  number,  and  the  subjacent  fibroblasts  are 
rapidly  converted  into  connective  tissue.  In  wounds  of  the  skin  which 
ileal  without  visible  granulations  the  i)apillae  are  absent  from  the  cicatrix, 
even  although  it  be  broad  from  subsequent  yielding  to  traction.  In 
wounds  healing  b}^  open  granulations  new  papillae  are  formed  in  the  new 
skin,  because  the  capillary  loops  atrophy  downward  and  become  the 
papillar}^  vessels.  Epidermization  and  cicatrization  are  favorablj^  influ- 
enced b}-  measures  which  secure  for  the  wound  an  aseptic  condition 
throughout,  and  by  keeping  the  delicate  granulations  covered  with  pro- 
tective silk  until  the  wound  is  completelj'  healed. 

POSITIVE  INDICATIONS  IN  THE  TREATMENT  OF  WOUNDS,  WITH  SPECIAL 
REFERENCE    TO    SECURE    UNION    BY    FIRST    INTENTION. 

Absolute  Asepsis. — AhsoUde  asepsis  can  only  be  secured  by  strictest 
antiseptic  measures.  Surgical  cleanliness  is  more  than  ordinary  clean- 
liness. 

Antiseptic  precautions  are  employed  for  the  purpose  of  securing  for 
the  wound  and  everything  that  is  brought  in  contact  with  it  an  aseptic 
condition.  The  mechanical  removal  of  microbes  from  the  field  of  opera- 
tion by  shaving  and  washing  with  warm  water  and  potash-soap  should 
be  as  thorough  as  possible,  but  cannot  be  relied  upon  in  securing  asepsis. 
The  surface  must  be  disinfected  with  a  reliable  germicidal  solution, either 
a  1-to-lOOO  solution  of  corrosive  sublimate  or  a  4-per-cent.  solution  of 
carbolic  acid.  Accidental  wounds  must  always  be  considered  as  infected 
wounds,  and  a  faithful  ertort  must  be  made  to  render  them  aseptic  by 
exposing,  if  possible,  the  entire  wounded  surface  to  the  direct  action  of 
one  of  these  solutions,  while  the  surface  for  a  considerable  distance 
around  it  is  also  disinfected.  Recentl}^  a  weak  solution  of  the  double 
cyanide  of  mercury  and  zinc  has  been  recommended  by  Sir  Joseph 
Lister  as  an  antiseptic,  and,  from  his  experimental  investigations  and 
clinical  experience,  it  appears  that  this  substance  possesses  an  advantage 
over  carbolic  acid,  corrosive  sublimate,  and  other  antiseptics,  as  it  exerts 
an  inhibitory  etleet  u{)on  microbes  which  still  may  remain  in  the  wound 
or  its  immediate  vicinity,  which  prevents  them  from  multiplying  in  tin; 
tissues  or  in  the  dressing.  The  hands  of  the  operator  and  his  assistants 
are  to  be  cleansed  by  washing  in  warm  water  and  potasii-soap.  and  then 
disinfected  in  a  1-to-lOOO  sublimate  solution,  and,  lastly,  washing  in  abso- 


24:  PRINCIPLES   OF    SURGERT. 

lute  iilcoliol.  Special  care  is  to  be  exercised  in  cleansing  and  disinfecting 
the  space  under  the  finger-nails.  On  each  side  of  the  wound  or  field 
of  operation  a  towel  wrung  out  of  an  antiseptic  solution  is  spread 
smoothly,  in  order  that,  during  the  operation,  instruments  and  sponges 
will  not  be  contaminated  by  being  brought  in  contact  with  non-aseptic 
clothing  or  surface.  None  but  sterilized  sponges  are  to  be  used,  and,  in 
the  absence  of  such,  pieces  of  aseptic  gauze,  folded  into  convenient 
shape,  shoukl  be  used  as  substitutes.  The  cheapest  and  most  reliable 
method  of  disinfection  of  instruments  is  to  boil  them  for  five  minutes 
and  then  plnce  them  upon  an  aseptic  towel,  ready  for  use.  If  these  anti- 
septic precautions  have  been  faithfully  carried  out,  sterilized  water  can 
1)6  used  for  irrigation  during  the  operation,  or  the  dry  method  of  operat- 
ing recently  introduced  into  practice  b}'  Landerer  can  be  followed  in 
operating  upon  aseptic  tissues  or  in  the  treatment  of  aseptic  wounds. 
In  the  operative  treatment  of  suppurative  affections,  irrigation  with  a 
l-to-5000  solution  of  sublimate  must  be  frequently  resorted  to  during 
tlie  operation,  and,  in  the  removal  of  tubercular  products,  irrigation  with 
an  aqueous  solution  of  the  tincture  of  iodine,  made  by  adding  enough 
of  the  tincture  to  sterilized  water  to  impart  to  the  solution  a  sherry 
color,  should  be  used. 

CAREFUL   H^MOSTASIS. 

Tlie  presence  of  a  blood-clot  between  the  surfaces  of  the  wound  is 
objectionable  for  the  following  reasons  :  1.  It  separates  mechanicallj''  the 
surfaces  which  it  is  intended  to  unite.  2.  It  serves  as  a  culture  medium 
for  micro-organisms,  which,  if  in  contact  with  living  tissue,  might  remain 
harmless.  3.  It  gives  rise  to  tension,  and  consequently  becomes  pro- 
ductive of  pain  and  an  undue  degree  of  reflex  irritation.  For  years,  von 
Bergmann  has  insisted  that  careful  arrest  of  haemorrhage  is  one  of  the 
most  urgent  and  important  indications  in  the  treatment  of  wounds,  and 
his  teachings  merit  the  attention  of  every  prudent  surgeon.  Bleeding 
points  should  be  tied  with  sterilized  catgut  or  silk.  A  number  of  sur- 
geons have  discarded  catgut,  as  it  is  more  difficult  to  render  it  aseptic 
than  silk.  The  latter  can  be  readily  sterilized  by  boiling.  The  haemor- 
rhage that  so  often  interferes  with  an  ideal  healing  of  the  wound  is  the 
capiihiry  or  parenchymatous  oozing,  and  this  should  always  be  carefully 
arrested  before  the  wound  is  sutured.  The  following  measures  should  be 
resorted  to  in  controlling  this  form  of  bleeding,  and  in  the  order  named: 
1.  Position.  2.  Surface  compression.  3.  Hot-water  irrigation.  4.  Anti- 
septic tampon. 

1.  In  wounds  of  the  extremities,  capillar}^  oozing  is  usuall}'  promptly 
arrested  by  holding  the  limb  in  a  perpendicular  position.  In  this  position 
the  intra-arterial  pressure  is  diminished  and  the  return  of  venous  blood 


ACCURATE    SUTURING.  25 

favored,  both  of  which  are  important  elements  in  diminishing  the  amount 
of  blood  in  the  capillar}^  vessels.  In  order  to  produce  the  desired  effect, 
this  position  should  be  maintained  for  fifteen  to  twent}'  minutes,  and  the 
limb  should  be  kept  in  this  position  for  at  least  six  hours  after  the 
operation. 

2.  Surface  pressure  with  a  flat  sponge  or  a  compress  mechanically 
arrests  the  bleeding,  and  the  capillary  vessels,  partl}^  or  completely 
emptied  of  blood,  are  placed  in  a  moi'e  favorable  condition  for  the  forma- 
tion of  a  thrombus.  After  an  amputation,  for  instance,  the  sponge  or 
compress  is  applied  to  the  surface  of  the  cut  muscles  and  the  flaps  are 
laid  over  it,  and  compression  with  two  hands  applied,  with  the  limb  in 
a  perpendicular  position  before  the  elastic  constrictor  is  removed.  Com- 
pression, continued  in  this  manner  for  ten  or  fifteen  minutes,  will  usually 
be  successful  in  completely  arresting  parench3'matous  bleeding. 

3.  Irrigation  with  water  at  a  temperature  sutlicienth'  high  to  coagu- 
late the  albumen  on  the  surface  of  the  wound  seals  mechanically  the  cut 
vessels,  and,  at  the  same  time,  produces  a  localized  anemia  by  contract- 
ing the  terminal  arterial  branches.  A  temperature  of  120°  F.  will 
answer  for  this  purpose. 

4.  St^^ptics  should  never  be  emploj^ed  in  arresting  bleeding  from  a 
recent  wound.  If  the  procedures  mentioned  fail  in  accomplishing  the 
desired  object,  the  wound  should  not  be  sutured  until  haemorrhage  has 
been  completely  checked  by  the  use  of  the  antiseptic  tampon.  The 
wound  is  packed  with  iodoform  gauze,  and  the  customarj'  dressing  is 
applied  in  such  a  manner  as  to  exercise  uniform  gentle  pressure.  After 
twenty-four  hours  the  dressing  and  tampon  are  removed,  and  the  wound 
closed  with  sutures.  In  such  cases  secondarj'  suturing  is  of  great  value 
in  securing  a  speed}'  and  satisfactory  healing  of  the  wound. 

ACCURATE    SUTURING. 

Brilliant  operators  are  not  alioays  the  best  surgeons.  The  best  results 
in  surgery  follow  the  one  who  is  most  jjainstaking  in  following  out  the 
minutest  details.  This  assertion  applies  most  forcibl}'  in  the  treatment 
of  wounds.  The  surgeon  here  occupies  the  position  of  handmaid  to  the 
vis  medicatrix  naturee.  and  in  the  exercise  of  his  duties  must  do  all  in 
his  power  to  tax  oid}-  to  a  minimum  extent  the  regenerative  resources 
of  the  wounded  tissues.  In  the  treatment  of  wounds  it  becomes  his 
imperative  duty,  not  only  to  unite  the  surfaces  of  the  wound  accurately 
and  neatly,  but  to  unite,  whenever  it  becomes  necessary,  tissues  of  the 
same  anatomical  structure  and  physiological  function.  Divided  nerves, 
tendons,  muscles,  fascia,  must  be  separately  united  with  buried  sutures 
before  the  wound  is  closed  by  the  ordinary  interrupted  or  continuous 


26  PRINCIPLES    OF    SURGERY. 

suture.  When  several  nerves  or  tendons  have  been  divided  in  the  same 
wound,  great  care  must  be  exercised  to  unite  the  ends  of  the  same  nerve 
or  tendon.  Accurate  approximation  of  a  deep  wound  is  impossible 
without  the  buried  suture.  Several,  rows  of  these  sutures  may  be  re- 
quired. Reliable  catgut  should  be  preierred  for  the  deep  sutures,  but 
if  this  material  is  not  at  liand  fine  silk  can  be  used.  The  best  materials 
for  the  ordinary  interrupted  sutures  are  silk  or  silk-worm  gut.  Separate 
sutures  for  the  skin  are  usually  required  in  order  to  approximate  the 
superficial  margins  of  the  wound  accurately.  If  the  surgeon  has  reason 
to  believe  that  the  wound  is  aseptic,  drainage  should  be  dispensed  witli, 
because  the  manuer  of  suturing,  as  just  described,  guards  against  the 
occurrence  of  "  dead  spaces."  An  absorbent  antiseptic  compress,  com- 
posed of  a  few  layers  of  iodoform  gauze  and  a  thick  layer  of  salicylated 
cotton,  or  sublimated  moss  or  wood-wool,  is  the  most  appropriate  dress- 
ing for  such  cases.  The  bandage  to  retain  this  dressing  is  applied  in 
such  manner  as  to  exercise  uniform  equable  compression, — an  important 
element  in  affording  support  to  the  injured  vessels  and  in  securing  rest 
for  the  parts  involved  in  the  injur3^ 

PHYSIOLOGICAL    REST. 

In  the  after-treatment  of  a  wound  nothing  is  more  important  than 
to  secure  for  the  parts  which  have  been  mechanically  united,  as  far  as 
possible,  physiological  rest.  The  importance  of  rest  in  the  prevention 
and  treatment  of  inflammation  has  been  prominently  brought  forward 
by  Hilton,  and  his  teachings  have  resulted  in  a  great  deal  of  good  in  the 
treatment  of  inflammatory  surgical  affections.  If  one  of  the  extremities 
is  the  seat  of  the  wound,  immobilization  upon  a  splint  or  with  a  plaster- 
of-P'im  (■'cssing,  in  such  a  position  as  to  relax  the  muscles  involved  in 
the  n  .  '  of  paramount  importance.  The  injured  part  must  be  kept 
in  a  position  wliich  will  favor  a  normal  blood-supply  and  prevent  passive 
liyperifimia.  A  wound  properly  dressed  should  not  be  disturbed  until 
union  has  taken  place.  If  any  one  of  the  three  most  important  indica- 
tions for  a  change  of  dressing — pain,  rise  in  temperature,  and  saturation 
of  the  dressing  with  wound-secretions — do  not  arise,  the  first  dressing  is 
allowed  to  remain  for  eight  days  to  six  weeks,  according  to  the  location, 
character,  or  size  of  the  wound.  In  wounds  of  the  gastro-intestinal 
canal,  physiological  rest  is  secured  by  abstinence  from  food,  and,  if 
necessary,  peristalsis  is  diminished  by  a  few  doses  of  opium.  In  wounds 
of  the  bladder  distention  of  the  organ  is  prevented  by  the  introduction 
and  retention  of  a  catheter.  In  Avounds  of  the  brain  or  its  envelopes, 
rest  is  secured  by  exclusion  of  light  and  by  enforcing  quietude  in  the 
patient's  room. 


UNION    BY    SECONDARY    INTENTION.  27 

UNION    BY    SECONDARY    INTENTION. 

In  an  aseptic  wound  all  the  new  material  resulting  from  proliferation 
of  the  fixed  tissue-cells  is  used  in  the  process  of  repair,  and  the  time  for 
healing  of  the  wound  will  depend  on  the  anatomical  structure  of  the 
part  injured  and  the  amount  of  material  required  to  form  a  bridge  of 
living  tissue  between  the  divided  parts.  As  long  as  the  wound  heals 
without  destruction  of  any  of  the  new  tissue-elements  by  specific 
microbic  causes,  it  is  proper  to  speak  of  a  union  by  primary  intention, 
whether  the  healing  is  completed  in  three  or  four  days,  or  whether  it  is 
protracted  for  months  until  the  ultimate  object  of  wound  treatment  has 
been  reached.  From  a  pathological,  and  even  from  a  practical,  stand- 
point, it  is  not  correct  to  include,  under  the  head  of  healing  by  the 
second  intention,  aseptic  wounds  that,  on  account  of  want  of  proper 
approximation,  or  on  account  of  loss  of  tissue,  have  of  necessity  to  heal 
by  granulation,  with  infected  wounds  in  which  the  regenerative  processes 
are  disturbed  by  suppuration.  In  a  suppurating  wound  the  embryonal 
cells  which  are  destined  to  become  transformed  into  new  tissue  are 
exposed  to  tlie  destructive  action  of  pus-microbes  and  their  ptomaines, 
their  protoplasm  is  destroyed,  and  the}'  become  one  of  the  histological 
sources  of  pus-corpuscles.  The  cells  on  the  surface  of  the  Avound,  being 
most  distant  from  the  vascular  suppl}',  possess  tlie  least  power  of  resist- 
ance to  the  action  of  pus-microbes,  and  on  this  account,  as  well  as  from 
the  greater  number  of  pus-microbes  on  the  surface  of  the  wound  than  in 
the  deeper  tissues,  they  are  converted  into  pus-corpuscles.  As  long  as 
suppuration  remains  active  the  superficial  layer  of  granulation  cells  are 
destroyed,  and  as  soon  as  other  embryonal  cells  take  their  place  the 
process  is  repeated,  and  thus  the  healing  of  the  wound  is  indefinitely 
delayed. 

Wlien  a  favorable  change  takes  place  in  the  wound,  either  spon- 
taneousl}'  or  from  the  employment  of  antiseptic  measures,  suppura- 
tion is  diminished,  the  granulations  become  firmer  and  more  vascular, 
and  cicatrization  and  epidermization  now  progress  in  a  satisfactory 
manner.  Such  a  favorable  change  in  the  condition  of  the  wound  can  be 
readil}'  explained  after  the  use  of  such  agents  as  are  known  to  destroy 
the  microbic  cause  of  the  suppuration  when  brought  in  contact  witli  the 
wound.  In  such  a  case  we  would  naturall}-  expect  that,  with  the  removal, 
destruction,  or  rendering  inert  of  the  pus-microbes,  the  embryonal  cells 
would  remain  attached  to  the  point  wliere  the}'  were  produced,  and  would 
soon  be  converted  into  tissue  resembling  the  matrix  which  produced 
them.  Spontaneous  cessation  of  suppuration,  and  with  it  the  conversion 
of  a  surface  covered  with  dead  material  into  a  healtii}'  granulating  sur- 
face, would  indicate  either  that  the   virulence  of  the  pus-microbes  had 


28  PRINCIPLES   OF   SURGERY. 

become  attenuated,  that  the  soil  was  no  longer  congenial  for  their  multi- 
jilioation,  or  finally  that  the  resistance  on  the  part  of  the  tissues  to  their 
pathogenic  action  had  become  increased.  That  tissue  resistance  has  a 
potent  influence  in  neutralizing  and  modifjnng  the  action  of  pathogenic 
micro-organisms  has  been  observed  clinically  and  demonstrated  experi- 
mentally. Suppurating  wounds  are  graver  atfections,  and  are  more 
difficult  to  manage  in  the  aged  and  in  badly-nourished  persons,  as  well 
as  in  patients  debilitated  from  excesses  and  other  protracted  diseases, 
A  good  circulation  of  tlie  part  is  an  important  element  in  counteracting 
the  cause  of  suppuration.  A  chronic  varicose  ulcer  of  the  leg  that 
suppurates  freely,  as  long  as  the  patient  continues  to  use  the  limb,  is 
often  transformed  into  a  healthy  granulation  surface  after  a  few  days  of 
rest  in  bed,  with  the  aftected  limb  in  an  elevated  position. 

TREATMENT    OF    SUPPURATING    WOUNDS,    WITH    SPECIAL    REFERENCE 
TO    HASTENING    THE   PROCESS    OF    REPAIR. 

In  the  treatment  of  an  accidental  Avound,  which  alwa3's  must  be 
regarded  as  a  septic  wound,  or  in  the  management  of  a  wound  where  the 
antiseptic  precautions  have  failed,  no  time  should  be  lost  in  securing  for 
the  wound  and  its  vicinity  an  aseptic  condition  by  tliorough  disinfection. 
The  surroundings  of  the  wound  are  disinfected  in  the  same  manner  as 
for  an  operation.  The  wound  is  exposed  as  thorouglih^  as  possiWe  to 
direct  treatment  b^'  enlarging  it  over  recesses  otlierwise  inaccessible, 
after  whicli  it  is  thoroughly  irrigated  with  a  solution  of  sublimate  (1  to 
2000).  If  the  granulations  are  copious  and  flabby  they  must  be  removed 
with  Volkmaun's  sharp  spoon,  and  after  the  bleeding  has  ceased  a 
12  per-cent.  solution  of  chloride  of  zinc  is  applied  ;  after  a  few  minutes 
the  surplus  fluid  is  washed  away  by  irrigation  with  the  sublimate  solu- 
tion. Tlie  wound  is  now  dried,  sutured,  and  drained.  Drainage  in 
these  cases  is  a  necessary  evil,  as  the  surgeon  can  never  feel  certain  that 
he  has  succeeded  in  obtaining  perfect  asepsis.  If  tlie  wound  is  extensive, 
or  if  pus  has  been  burrowing  in  different  directions  along  the  deep 
tissues,  as  in  cases  of  compound  fracture  where  a  thorough  disinfection 
of  every  part  of  the  wound,  as  described  above,  is  impossible  or  imprac- 
ticable, constant  irrigation  with  a  saturated  solution  of  acetate  of 
aluminum  should  be  instituted  and  continued  until  the  wound  has  been 
rendered  aseptic.  Acetate  of  aluminum  is  a  reliable  antiseptic,  is  non- 
toxic, and  penetrates  the  tissues  deeply.  The  treatment  most  appro- 
priate for  a  recent  aseptic  wound  is  to  be  adopted  as  soon  as  suppuration 
has  ceased  and  the  general  symptoms  at  the  same  time  point  to  an 
aseptic  condition. 


SUTURING    OF   GRANULATrNG    WOUNDS.  29 

SUTURING  OF  GRANULATING  AYOUNDS. 
If  union  by  primary  intention  has  failed  to  take  place  for  any  reason 
in  wounds  which  can  be  closed  by  suturing,  a  second  attempt  can  be 
made  to  approximate  the  surfaces  with  sutures  with  fair  prospects  of 
success  as  soon  as  the  granulations  are  in  an  aseptic  condition.  Aseptic 
granulating  surfaces  when  brought  in  contact  unite  rapidly,  as  vascular 
connections  between  the  new  capillary  loops  are  established  in  a  remark- 
ably short  time,  and  the  wound  then  heals  in  the  same  manner  as  after 
primary  suturing.  The  cases  best  adapted  for  secondary  suturing  are 
those  where  suppuration  has  ceased,  the  granulations  have  become  small 
and  firm, — in  short,  wounds  in  which  cicatrization  has  commenced.  The 
technique  in  the  treatment  of  such  wounds  is  the  same  as  in  cases  of 
aseptic  recent  wounds.  The  advantages  of  this  method  of  dealing  with 
wounds  that  have  failed  to  unite  are  pronounced  when  the  wound  is  deep 
and  the  margins  can  be  coaptated  without  much  tension.  Buried  sutures 
can  be  used  for  the  same  purpose  and  witli  the  same  benefit  as  in  the 
treatment  of  recent  wounds.  Before  the  surfaces  are  brought  in  contact 
with  the  svitures  it  is  important  to  disinfect  and  dr}'  the  granulations 
thoroughly.  As  secondary  suturing  is  applicable  only  in  tlie  treatment 
of  such  wounds  where  we  have  every  reason  to  assume  that  an  aseptic 
condition  exists,  or  can  be  secured  by  disinfection,  the  whole  wound 
should  be  carefully  closed  and  drainage  must  be  dispensed  with,  in  order 
to  obtain  rapid  healing  of  the  entire  wound.  It  has  been  recently 
suggested  by  Kahn  that  in  extensive  defects  of  the  skin  a  covering  for 
the  wound  can  be  obtained  by  sliding  of  the  skin,  after  undermining  it  for 
some  distance  in  a  direction  most  suitable.  That  this  procedure  is 
applicable  only  under  circumstances  when  the  surgeon  is  sure  of  asepsis 
is  to  be  taken  for  granted,  as  otherwise  it  might  be  followed  by  gangrene 
and  still  greater  loss  of  tissue. 


CHAPTER  II. 

Regeneration  of  Different  Tissues. 

In  connection  with  the  subject  of  healing  of  wounds  it  is  veiy 
important  for  the  student  to  familiarize  himself  with  the  vegetative 
capacity  of  the  different  tissues  of  the  body  in  order  to  estimate  with 
some  degree  of  acciirac}'  the  part  taken  b}'  each  tissue  in  the  reparative 
processes  which  take  place  after  an  injur}-  or  disease.  No  positive  proof 
has  yet  been  furnished  that  the  leucocytes  or  any  other  of  the  cellular 
elements  of  the  blood  take  any  active  part  in  the  restoration  of  lost  jmrts. 
It  does  not  appear  to  me  reasonable  or  logical  that  such  an  indifferent 
cell  as  the  leucoc3'te  should  ever  become  transformed  directl}-  into  a 
fixed  tissue-cell,  and  it  is  still  more  improbable  that  it  should  be 
possessed  with  such  a  diverse  vegetative  capacity  as  to  undergo  a  transi- 
tion in  one  place  into  a  connective-tissue  cell,  in  another  into  bone,  and 
still  another  into  a  muscle-fibre.  It  is  much  more  rational  to  assume, 
in  the  repair  of  an  injury  and  in  the  regeneration  of  a  part  destroj'ed 
b}'  disease,  that  the  universal  law  of  legitimate  succession  of  cells  asserts 
itself,  according  to  which  the  reparative  process  is  initiated  and  completed 
b}'  homologous  cell  proliferation. 

In  the  following  pages  experimental  and  clinical  proofs  will  be 
advanced  which  will  at  least  tend  to  establish  the  truth  of  this  assertion. 

NON-VASCULAR   TISSUE. 

The  part  taken  by  blood-vessels  in  regenerative  processes  is  well 
shown  in  the  healing  of  wounds  of  non-vascular  tissue.  Large  wounds 
of  the  cornea  and  cartilage  can  onl}-  heal  after  a  blood-supply  has  been 
established  through  new  vessels  from  the  nearest  vascular  district. 
Rapid  vascularization  of  the  non-vascular  tissues  is  alwaj's  observed 
when  the  wound  has  become  infected. 

Copnea. — Tlie  normal  cornea  contains  no  blood-vessels,  but  vascular 
spaces,  which  form  a  system  of  channels  for  the  circulation  of  the  plasma- 
fluid.  In  1863  Recklingliausen  discovered  in  these  spaces  migrating 
corpuscles,  resembling  in  size  and  shape  the  white  blood-corpuscle,  which 
be  regarded  as  off'springs  of  the  corneal  corpuscles.  Later,  Cohnheim 
showed  that  these  wandering  cells  were  leucocytes  which  had  escaped 
from  the  pericorneal  capillary  vessels  and  had  found  their  Avny  into  these 

(31) 


82  PRINCIPLES   OF    SURCERY. 

cluinnels.  In  traumatic  keratitis  these  spaces  become  blocked  with 
leucocytes,  and  they  constitute  largely'  tlie  primar}'  product  of  inflam- 
matory exudation  \ong  before  the  fixed  cells  of  the  coruea  could  have 
yielded  such  an  amount  of  cellular  elements.  Struhe  niul  His  studied 
experimentally  the  healing  of  wounds  of  the  cornea  and  traumatic  kera- 
titis. They  injured  the  cornea  of  rabbits  by  cutting  and  ca/uLerization. 
As  the  cornea  is  freel}^  supplied  with  nerves,  thej^  observed  as  one  of  the 
earliest  tissue  changes  a  reflex  paretic  dilatation  of  the  marginal  1)loo(l- 
vessels.  The  marginal  hyperemia  was  followed  by  the  formation  of  new 
blood-vessels  in  the  direction  of  the  seat  of  injury.  The  early  opacity 
around  the  wound  and  the  space  between  the  wound  and  the  advancing 
channels  are  caused  by  the  presence  of  leucoc^ytes  in  the  vascular  spaces  ; 
later,  to  proliferation  of  the  corneal  corpuscles.  That  leucoc3'tes  enter 
the  plasma-canals  when  the  cornea  is  irritated  has  been  definitely  settled 
by  Cohnheim  by  one  of  his  most  ingenious  experiments.  He  injected 
finel^'-divided  carmine  suspended  in  an  acid,  or  precipitated  aniline  into 
the  dorsal  lymph-sacs  of  frogs,  with  the  result  that  when  he  irritated 
the  cornea,  a  few  days  later,  leucocytes  stained  with  the  pigment-material 
appeared  at  the  margin  of  the  cornea  where  cell-migration  was  known  to 
appear  first.  He  found  a  rai)id  increase  of  corneal  corpuscles  in  the 
animal  subjected  to  experimentation  ;  thus,  in  one  instance,  eighteen 
hours  after  the  injury,  he  found,  in  spaces  normally  occupied  by  one 
corpuscle,  as  many  as  20  to  30  young  cells  closely  packed  together. 

Hamilton  regards  as  the  first  change  in  an  irritated  cornea  an  in- 
crease of  the  plasma-current  which  may  destroy  the  endothelial  lining 
of  the  canals,  and  according  to  this  observer  cell-migration  into  the 
corneal  spaces  occurs  later.  Unimpaired  innervation  of  the  cornea  is 
an  important  factor  in  the  prompt  healing  of  wounds  of  this  structure, 
as  it  is  well  known  that  in  patients  suffering  from  glaucoma,  and  in  the 
aged,  wounds  of  the  cornea  heal  often  in  a  very  unsatisfactory  manner. 
An  aseptic  wound  of  a  normal  cornea  heals  without  opacit}^ ;  the  new 
corneal  corpuscles,  after  they  attain  maturit}'^,  transmit  light  as  perfectly 
as  the  cells  from  which  they  are  produced.  Imperfect  restoration  of 
tissue  is  to  1)e  expected  when  the  regenerative  process  is  complicated  by 
a  suppurative  inflammation  with  considerable  destruction  of  tissue. 
Gussenbauer  incised  the  cornea  in  rabbits  half-way  between  the  centre 
and  its  margin  to  the  extent  of  half  a  line  to  a  line,  and  found,  in  exam- 
ining the  specimens  after  twenty-four  hours,  that  no  union  had  taken 
place.  The  wound-surfiices  at  this  time  were  glued  together  by  an  inter- 
posed substance.  The  surfaces  of  the  wound  were  in  close  contact 
at  a  point  corresponding  to  the  middle  portion  of  the  cornea,  and  the 
gap  widened  toward  each  of  its  surfaces  so  that  the  temporary  cement- 


NON-VASCULAR   TISSUE. 


33 


substance  represented  two  cones  with  their  apices  directed  toward  each 
other  and  the  bases  toward  the  surfaces.  On  staining  the  specimens 
with  chloride  of  gold  it  was  found  that  this  substance  contained  cells 
which  were  most  numerous  toward  the  surfaces  of  the  cornea.  The  cor- 
neal corpuscles  on  the  cut  surfaces  were  seen  to  be  enlarged  and  presenting 
different  stages  of  cell-division.  Instead  of  round  the  corpuscles  were 
spindle-shaped,  some  containing  one  nucleus,  others  two  nuclei ;  intercellu- 
lar substance  granular.  In  specimens  eight  days  old  the  space  between  the 
cut  surfaces  was  occupied  almost  exclusively  by  new  corneal  corpuscles, 
and  the  edges  of  the  wound  could  no  longer  be  clearly  defined.  During 
cicatrization  of  the  wound  the  number  of  cells  is  diminished,  while  in 
form  and  size  the}'  resemble  more  and  more  the  mature  corneal  corpuscles 
from  which  they  were  derived. 

In  a  non-penetrating  incised  wound  of  the  cornea  the  gap  is  filled 


Fig.  18.— Corneal  Corpuscles  in  a  State  of  Proliferation.    (Sen/tleben.) 

A,  old  corneal  corpuscles  with  one  or  two  nuclei  and  young  o£fshoot3,  B  and  C. 


up  after  a  few  daj-s  with  young  cells  derived  from  the  C3'lindrical  cells 
of  the  deepest  la3'er  of  the  corneal  epithelia. 

If  the  w^ound  has  penetrated,  the  posterior  third  of  the  wound  gaps 
toward  the  anterior  chamber  of  the  eye,  and  is  first  plugged  with  the 
products  of  coagulation  necrosis,  which  is  later  replaced  by  epithelial 
cells  from  the  niembrana  Descemeti  (Fig.  19,  C),  while  the  anterior  por- 
tion is  occupied  by  epithelial  cells  the  same  as  in  the  non-penetrating 
wounds.  At  the  end  of  the  first  week  the  corneal  corpuscles  begin  to 
proliferate,  and  the  cells  from  this  source  gradually  displace  the  epithe- 
lial cells  and  bring  nliout  the  definitive  healing  of  the  wound.  As  wounds 
of  the  cornea  are  not  sutured,  the  surgeon  should  aim  to  secure  approxi- 
mation by  i-LMuoving  coagulated  blood  if  present, and  by  correcting  any  dis- 
placements wliich  may  be  present  by  direct  measures,  and  finally  b}^  apply- 
ing a  dressing  which  will  exert  uniform  and  equable  elastic  compression. 


34 


PRINCIPLES   OF   SURGERY. 


Although  the  antiseptic  treatment  cannot  be  carried  out  with  the  same 
precision  in  the  treatment  of  wounds  of  tlie  cornea  as  in  other  localities, 
it  is  at  least  the  duty  of  the  surgeon  to  use  only  sterilized  instruments 
and  aseptic  sponges,  and  to  employ  such  mild  antiseptic  solutions  as  will 
at  least  exercise  an  inhibitory  influence  upon  pathogenic  micro-organisms 
that  may  be  present  in  the  wound  or  upon  the  surface  of  the  eye. 

Cartilage. — Cartilage  is  in  every  sense  of  the  word  a  non- vascular  struc- 
ture, as  even  the  plasma-channels  found  in  the  cornea  are  absent  here. 
Plasma  diffusion  must  take  place  between  or  through  the  cells.     It  is  un- 


FiG.  19.— Wound  of  Cornea,    {von  Wpss.) 
A-A',  new  corneal  corpuscles  ;  B-A',  temporary  plug  of  fibrin  ;  C,  epithelia  from  membrana  Descemeti. 

doubtedly  on  account  of  thelimited  provisions  for  nutritive  supply  that  the 
vegetative  capacity  of  this  tissue  is  so  exceedingly  low.  Normal  cartilage 
when  injured  is  unable  to  repair  the  defect.  The  process  of  healing  of 
Avounds  of  cartilage  was  first  studied  experimentally  by  Redfern.  In 
one  experiment  he  found  the  wound  almost  unchanged  after  twenty-nine 
days.  In  one  specimen,  where  the  healing  process  had  been  completed, 
he  found  the  defect  repaired  by  connective  tissue.  The  microscopical 
description  of  the  healing  process  corresponded  witli  that  given  by 
Goodsir  of  inflammatory  processes  in  this  structure.    Along  the  margins 


VASCULAR   TISSUE.  35 

of  the,  wound  the  cartilage-cells  multiply  and  the  cement-substance  is 
dissolved.  No  new  cartilage-cells  are  produced,  and  the  space  is  occu- 
pied by  connectiA'e  tissue.  Vascularization  toward  the  seat  of  injur}'- 
from  the  marginal  A^essels  of  the  perichondrium  takes  place  in  the  same 
manner  as  in  the  cornea.  Reitz  traced  the  formation  of  connective  tissue 
from  the  cartilage-cells  in  tracheotomy^  wounds  in  rabbits.  He  observed, 
after  the  cement-substance  had  become  dissolved,  that  the  cartilage-cells 
were  transformed  into  spindle-cells,  and  later  into  connective  tissue.  He 
found  the  gap  between  the  divided  cartilage-ring  filled  with  such  cells  a 
few  days  after  the  wound  had  been  inflicted,  and  explains  the  discrep- 
ancy between  the  results  he  obtained  and  those  described  by  Redfern  on 
the  ground  of  the  close  proximity-  of  vascular  suppl}^  in  his  case  and  the 
remoteness  of  vessels  from  the  wound  studied  by  Redfern,  as  the  latter 
experimented  on  articular  cartilage.  Gussenbauer  studied  the  repair  of 
cartilage  wounds  after  incising  subcutaneousl}-  costal  cartilage.  In  wounds 
twenty-four  hours  old  a  triangular  gap  was  found  filled  with  fibrin  and 
blood-corpuscles.  No  change  was  found  at  this  time  in  the  cartilage- 
cells  and  cement-substance.  The  cells  of  the  perichondrium  increased  in 
volume  and  changed  in  form.  Gussenbauer  was  unable  to  verify  the 
observation  made  by  Reitz  in  wounds  of  trachea,  that  cartilage-cells  are 
transformed  into  connective-tissue  cells,  and  believes  that  the  ammonia 
used  by  Reitz  to  provoke  croupous  pneumonia,  bv  its  introduction  into 
the  bronchial  tubes  through  the  tracheal  wound,  may  liave  modified  the 
result.  He  traces  tissue  proliferation  almost  exclusivel}'  to  the  peri- 
chondrium, the  cells  of  which  were  found  in  all  stages  of  division  and 
development,  while  only  a  few  of  the  cartilage-cells  presented  CAidences 
of  segmentation.  Corner  studied  not  only  the  manner  of  repair  of 
simple  incised  wounds  of  cartilage,  but  also  produced  more  complicated 
injuries,  and  invariably  found  that  the  perichondrium  took  a  more  active 
part  in  the  process  of  healing  than  the  cartilage-cells.  Wounds  of  fibro- 
and  reticulated  cartilage  heal  in  the  same  manner  as  wounds  of  hyaline 
cartilage.  The  histological  changes  observed  hy  Redfern,  Corner,  and 
Gussenbauer  during  the  repair  of  wounds  of  cartilage  are  descriptive  of 
the  changes  which  attend  chondritis. 

VASCULAR    TISSUE. 

The  healing  of  wounds  of  vascular  tissue  is  accomplished  more 
rapidl}^  than  of  non-vascular  tissue,  as  the  primary  wound-secretion, 
which  is  derived  mostl}'  from  the  wounded  vessels,  forms  a  temporary 
cement-substance  which  glues  tlie  parts  together, — a  condition  which 
renders  material  assistance  in  maintaining  coaptation, — wliile  the  direct 
blood-supply  to  the  injured  part  cannot  fail  in  increasing  the  vegetative 


36  PRINCIPLES   OF    SURGERY. 

capacity  of  the  cells,  and,  lastly,  the  leucocytes  present  in  the  recent 
wound  serve  as  food  for  the  cells  which  are  undergoing  karyokinetic 
changes.  As  a  rule,  to  which  there  are  few  exceptions,  it  may  be  stated 
that  the  rapidity  with  which  the  healing  process  is  completed  is  propor- 
tionate to  the  vascularity  of  the  wounded  part.  For  instance,  wounds 
of  the  fingers  heal  much  more  rapidl}'  than  wounds  of  the  arm  or  fore- 
arm, and  wounds  of  the  face  more  rapidly  than  wounds  of  the  neck. 
Karyomitotic  changes  are  first  noticed  in  the  nuclei  of  cells  in  close 
proximity  to  blood-vessels.  In  studying  the  healing  of  wounds  of 
vascular  tissue,  Graser  noticed  that  the  connective-tissue  cells  a  little 
distance  from  the  surface  of  the  wound  were  first  to  show  evidences  of 
karyokinetic  changes  ;  hence,  it  is  apparent  that  the  reparative  process 
is  initiated  in  cells  most  favorably  located  in  reference  to  an  abundant 
blood-supply,  which  corresponds  to  the  location  of  capillary  vessels 
which  are  undergoing  dilatation  prior  to  the  formation  of  new  blood- 
vessels. Regeneration  of  tissue  takes  place  most  rapidly  in  parts  where 
new  blood-vessels  are  developed  earh%  rapid)}-,  and  abundantl}'.  The 
healing  process  is  retarded  or  completely  suspended  when  the  capillar}^ 
vessels,  new  and  old,  are  seriously  altered  by  inflammation. 

Surface  Epithelia. — Epithelial  cells  in  a  normal  condition  receive  no 
direct  blood-supply,  but  their  relations  to  the  subjacent  vascular  tissue 
are  so  intimate,  and  their  proliferation  in  the  healing  of  surface  wounds 
and  in  the  repair  of  defects  caused  by  pathological  conditions  is  so 
largely  dependent  on  the  development  of  new  blood-vessels,  that  the 
study  of  their  regeneration  among  the  vascular  tissues  appears  appro- 
priate. In  the  consideration  of  this  subject  of  epidermization,  it  has 
been  shown  that  epithelial  cells  are  derived  exclusivel}^  from  an  epithelial 
matrix,  either  from  the  margin  of  the  wound  or  an  islet  of  the  epiblast 
buried  among  the  granulations.  Regeneration  of  epithelial  cells  of  the 
hypoblast  takes  place  in  a  similar  manner  as  has  been  described  in 
epidermization  of  a  wound  of  the  cutaneous  surface.  Of  special  intei'est 
is  the  rapid  regeneration  of  the  gastro-intestinal  mucous  membrane. 
A  recent  gastric  or  intestinal  ulcer  presents  elevated  and  swollen 
margins,  and  as  long  as  this  condition  remains  the  healing  process  fails 
to  become  established  until  the  swelling  subsides,  and  paving  of  the 
granulations  with  epithelial  cells  is  postponed  until  the  surface  of  the 
ulcer  is  nearly  on  the  same  level  with  the  surrounding  border  of  the 
mucous  membrane.  Griffini  and  Vassale  made  gastric  fistulfe  in  dogs 
for  the  purpose  of  studying  directly,  and  during  the  life  of  the  animals, 
the  process  of  repair  of  wounds  of  tlie  mucous  membrane  of  the  stomach. 
Through  the  fistula  they  made  superficial  wounds  of  the  inner  surface 
of  the  organ,  and  from  their  observations  they  satisfied  themselves  that 


VASCULAR   TISSUE.  37 

healing  takes  place  rapidly,  and  that  regeneration  of  epithelial  cells 
occurs  in  the  peptic  glands,  where  even  as  early  as  the  tliird  day  the 
epithelial  cells  showed  evidences  of  active  proliferation.  The  new 
epithelial  cells  spread  over  the  interglandular  spaces,  while  a  part  of  the 
glandular  structure  is  lost  during  the  process  of  healing.  In  traumatic 
defects  wliere  the  glands  have  been  excised  with  the  mucous  membrane 
the  epithelial  covering  of  the  granulating  surface  is  derived  from  the 
preformed  epithelial  cells  of  the  mucous  membrane  bordering  the  wound. 
At  a  later  stage  new  glands  are  formed  by  karj'omitotic  cellular  changes 
after  the  normal  type  of  development  of  glands  in  the  embryo.  Even 
the  3'oungest  glands  have  an  outlet,  and  the  structure  increases  in  depth 
by  extension  of  mitotic  changes  in  that  direction.  Pepsin-secreting  cells 
are  found  onl}'  after  the  glands  have  attained  nearl}^  their  normal  depth. 
In  one  instance  they  were  found  onl^^  partly  developed  on  the  fortieth 
da3\  Connective-tissue  proliferation  takes  no  essential  part  in  the 
growth  and  development  of  the  new  glands.  Visceral  wounds  of  the 
stomach  heal  kindl}-  and  rapidl}'.  Even  gunshot  wounds  of  this  organ, 
when  made  with  a  small  bullet,  ma}-  heal  without  surgical  interference, 
more  especially  if  at  the  time  the  injnr\'  has  been  inflicted  the  stomach 
is  empty  and  all  food  is  withheld  for  a  few  days.  A  strict  diet  is 
important  in  the  treatment  of  wounds  or  ulcers  of  the  stomach,  as  Leube 
has  obtained  excellent  results  from  treatment  of  chronic  ulcers  of  this 
organ  by  an  exclusive  milk  diet.  Grittiui  also  made  the  observation  that 
the  traumatic  defects  which  he  produced  in  the  interior  of  the  stomach 
of  dogs  healed  most  rapidly  when  food  was  withheld  entirel}'  for  a  few 
days,  and  later  on  nothing  but  milk  was  allowed.  From  these  observa- 
tions and  experiments  it  is  evident  that  the  j'oung  cells  are  unfavorabl}' 
affected  by  the  action  of  the  gastric  juice. 

Quincke  has  demonstrated  experimentall3\  which  has  been  a  long- 
known  and  familiar  clinical  fact,  that  angeraia  retards  regeneration  of  the 
gastro-intestinal  mucous  membrane.  In  two  dogs  a  gastric  fistula  was 
made,  and  through  it  a  defect  of  the  mucous  lining  was  made  of  the  same 
size  in  both  animals.  One  of  the  animals  was  in  perfect  health,  and 
healing  was  completed  in  eighteen  days.  The  other  dog  was  anaemic, 
and  the  healing  process  was  prolonged  thirty-one  days.  In  the  healing 
of  an  ulcer  of  the  stomach  or  an}^  portion  of  the  intestinal  canal  the 
epithelial  cells  are  first  to  take  an  active  part  in  establishing  a  process 
of  repair,  the  connective-tissue  cells  entering  later  upon  their  part  of 
tissue  production.  The  heahng  process  terminates  most  satisfactorily 
when  only  a  small  amount  of  connective  tissue  is  formed  and  the 
epithelial  covering  is  completed  in  a  short  time,  as  such  a  scar  represents 
almost   to   perfection   the    normal   tissue   it   has   replaced.     If  a  large 


38  PRINCIPLES   OF    SURGERY. 

quantity  of  granulation  tissue  is  produced  by  the  connective  tissue,  and 
the  formation  of  the  epithelial  covering  is  delayed  for  a  long  time,  or  is 
imperfectl}'  accomplished,  there  is  great  danger  of  subsequent  cicatricial 
contraction  of  the  new  tissue  producing  a  stricture.  The  best  possible 
prophylactic  means  against  the  occurrence  of  strictures  under  such 
circumstances  are  suck  dietetic  and  therapeutic  measures  as  will  secure 
for  the  ulcerated  or  wounded  surface  such  favorable  conditions  as  will 
expedite  the  paving  of  the  surface  with  epithelial  cells  and  limit  the 
production  of  cicatricial  tissue. 

TRANSPLANTATION    OF    SKIN. 

Epiderraization  of  a  large  granulation  surface  is  a  slow  process, 
even  under  the  most  favorable  circumstances,  and  the  resulting  cicatrix 
is  often  large,  gives  rise  to  contractions,  and  not  infrequently  becomes 
the  seat  of  keloid  or  ulcerative  processes  subsequent!}'.  Modern  surgery 
offers  means  by  which  this  tedious  process  can  be  materially  shortened, 
and  healing  is  accomplished  by  the  formation  of  a  moi'e  satisfactory  scar. 

Skin-grafting  to  Expedite  the  Healing  of  Granulating  Surfaces. — In 
1810  Reverdin  discovered  that  small,  thin  pieces  of  superficial  skin, 
transplanted  upon  a  healthy,  granulating  surface,  formed,  in  a  short  time, 
organic  connections  with  the  granulations,  and  that  epidermization  pro- 
ceeded independentlj'  from  such  transplanted  islets  of  skin.  Later, 
Schwenninger  demonstrated,  by  his  experiments,  that  hairs  could 
similarly  be  transferred  to  a  granulating  surface.  An  open,  granulating 
wound  or  ulcer  can  be  covered  over  with  epidermis  in  a  short  time  by 
resorting  to  Reverdin's  method  of  transplantation  of  skin.  The  most 
essential  condition  for  success  is  an  aseptic  condition  of  the  granulations. 
In  suppurating  wounds  this  method  of  treatment  is  not  applicable  until 
suppuration  has  ceased  and  the  granulations  are  small  and  firm.  The 
part  from  which  the  skin  is  to  be  taken,  in  preference  the  thigh  or  arm, 
should  be  shaved  and  disinfected.  The  only  instruments  required  for 
cutting  and  transferring  the  skin  is  an  ordinary  sewing-needle  fixed  in  a 
needle-holder,  or,  what  is  still  better,  a  pair  of  haemostatic  forceps  and  a 
sharp  razor.  With  the  needle  the  skin  is  transfixed,  and  with  a  razor  a 
thin  section  the  size  of  the  circumference  of  a  split  pea  is  removed  and 
at  once  transferred  to  the  granulating  surface  with  the  needle  in  such  a 
manner  that  the  cut  surface  is  l)rouglit  accurately  in  contact  with  the 
granulations.  As  the  detached  portion  of  skin  always  curls  toward  the 
raw  surface  at  its  margins,  it  must  be  cnrefully  fiattened  out  with  tlie 
point  of  one  or  two  needles,  care  being  taken  to  imbed  it  well  among 
the  granulations  without  causing  any  bleeding.  The  grafts  are  planted 
in  rows,  commencing  near  the  border  and  leaving  small  spaces  between 


TRANSPLANTATION    OF    SKIN.  39 

the  separate  grafts.  Each  row  of  grafts  is  then  separately  protected 
with  a  narrow  strip  of  protective  silk,  and  a  thick,  antiseptic  compress 
is  applied  and  retained  by  a  bandage,  which  should  exercise  uniform 
gentle  compression.  The  dressing  should  not  be  removed  in  less  than  a 
week.  At  this  time  the  grafts  will  not  only  have  become  firmly  attached 
to  the  subjacent  surface,  but  each  of  them  has  become  surrounded  Avith 
a  zone  of  new  epithelial  cells.  As  each  graft  now  constitutes  an  inde- 
pendent centre  of  epithelial  proliferation,  the  remaining  portion  of  the 
granulation  surface  soon  becomes  paved  by  new  epithelial  cells,  and 
epidermization  and  cicatrization  are  rapidly  completed.  The  results 
obtained  by  this  method  of  treatment  have  not  always  been  such  as  to 
satisf^-^  the  earlier  expectations.  The  new  skin  is  but  a  poor  substitute 
for  the  normal  structure.  Epidermization  is  hastened,  and  the  results 
are  better  than  after-healing  without  skin-grafting,  but  the  ideal  result, 
the  formation  of  tissue  resembling  true  skin,  is  not  obtainable  by  this 
method  of  skin  transplantation. 

Skin-grafting  in  the  Treatment  of  Recent  Wounds. — If  after  an 
operation  or  injur3^  it  is  found  that  a  too  extensive  defect  of  the  skin 
renders  approximation  b}'  suturing  impossible,  the  surgeon  has  it  now 
in  his  power  to  supply  the  defect  at  once  by  taking  large  skin-grafts 
from  another  part  of  the  bod}-,  or  from  another  person,  and  planting 
them  in  the  form  of  a  mosaic  upon  the  raw  surface.  This  method  of 
skin-grafting  in  the  treatment  of  extensive  superficial  wounds,  as  after 
the  extirpation  of  a  lupus,  or  a  surface  epithelioma,  was  devised  by 
Thiersch.  Experience  has  shown  that  grafts  of  the  whole  thickness  of 
the  skin,  and  an  inch  square,  if  planted  smoothly'  upon  the  raw  surface 
and  kept  uninterruptedl}'  in  contact  with  the  wound  by  an  appropriate 
dressing,  not  only  retain  their  vitalitj*,  but  enter  rapidly  into  organic 
connections  with  the  part  with  which  tliey  have  been  brought  into  con- 
tact, and,  at  the  same  time,  their  anatomical  and  physiological  properties 
are  maintained  to  perfection.  Thiersch  found  that  after  eighteen  hours 
they  were  supplied  with  new  blood-vessels,  which  could  be  successfully 
injected  from  the  vessels  of  the  part  to  which  the}"  had  become  adherent. 
This  method  of  transplantation  of  skin  is  now  extensively  practiced  in 
connection  with  plastic  operations  about  the  face.  For  such  purposes 
the  skin  is  taken  from  the  region  of  the  trochanters,  as  the  skin  here  is 
almost  or  entirely  devoid  of  hair.  All  bleeding  from  the  wound  to  be 
covered  with  the  grafts  is  carefull}'  arrested  by  surface  pressure  before 
the  grafts  are  planted,  as  it  is  necessar}^  to  secure  accurate  coaptation  of 
the  wound-surfaces  in  order  to  secure  a  favorable  result.  Tlie  modern 
method  of  performing  rhinoplast}-  furnishes  a  good  illustration  of  this 
method  of  skin  transplantation. 


40 


PRINCIPLES   OF    SURGERY. 


As  a  matter  of  course,  success  by  this  method  of  skin  transplanta- 
lion  can  only  be  expected  when  the  wound  and  grafts  are  aseptic,  and 
tlie  parts  are  kept  in  this  condition  at  least  until  vascularization  of  the 
grafts  has  taken  place.  After  the  grafts  have  been  planted  the  treat- 
ment of  the  wound  is  the  same  as  in  Reverdin's  method.  During  the 
after-treatment  it  is  important  to  secure  rest  for  the  part,  and  to  prevent, 
by  appropriate  means  of  fixation,  even  the  slightest  displacement  of  the 
grafts  in  any  direction.     A  good  plan  is  to  apply  a  thin  plaster-of-Paris 


Fig.  20.— Rhinoplasty  and  Transplantation  of  Large  Skin-grafts.    (Thiersch.) 

A,  A,  skin-flaps  from  face  turned  inward  and  covered  with  large  flap  from  forehead,  C  after  C,  and  B 
after  B'.     Defects  covered  with  mosaic  of  large  skin-grafts  from  troclian  teric  region. 

bandage  over  the  dressing,  Scliede  has  substituted  Thiersch's  for  Re- 
verdin's method  in  the  treatment  of  granulating  surfaces  by  skin-graft- 
ing, and  the  results  have  been  very  gratifying.  The  granulating  surface 
is  transformed  into  a  recent  aseptic  wound  by  removing  the  granulations 
with  a  sharp  spoon.  After  all  bleeding  has  ceased  the  wound  is  covered 
with  large  skin-grafts  in  the  manner  described.  The  skin  obtained  after 
this  method  of  transplantation  presents  a  normal  appearance.  I  have 
repeatedly  seen  that,  after  excision  of  an  epithelioma  of  the  frontal  or 
parietal  region,  a  defect  the  size  of  the  palm  of  the  hand  was  healed 


CONNECTIVE    TISSUE.  41 

completel}-  in  less  than  three  weeks  b}-  using  Thiersch's  grafts.  This 
method  of  skin-grafting  must  be  a  welcome  resource  to  the  oculists  in  the 
operative  removal  of  tuberculous  lesions  and  malignant  affections  of  the 
eyelids,  as  well  as  in  the  treatment  of  some  forms  of  ectropion. 

Transplantation  of  Mucous  Membrane. — In  the  treatment  of  traumatic 
or  ulcerative  defects  of  accessible  mucous  membranes,  it  would  seem 
that  restoration  of  the  defect  by  transplantation  of  grafts  of  mucous 
membrane,  if  found  feasible,  would  be  the  ideal  treatment.  Wolfler  has 
recently  shown  that  such  a  method  of  treatment  is  not  only  practicable, 
but  has  resorted  to  it  successfully  in  the  treatment  of  obstinate  strictures 
of  the  urethra.  After  excision  of  the  cicatrix  at  the  seat  of  resection 
he  sutured  a  circular  graft  of  mucous  membrane  to  each  end  of  the 
resected  urethra,  and  had  the  satisfaction  to  observe  that  the  graft  not 
only  retained  its  vitality,  but  became  adherent  and  constituted  an 
essential  part  of  the  new  portion  of  the  urethra.  Wolfe  has  also  suc- 
ceeded in  transplanting  the  whole  of  the  tissues  of  the  conjunctiva  of 
the  rabbit  onto  that  of  man  in  order  to  fill  a  defect  caused  by  cicatricial 
contraction.  This  method  of  dealing  with  large  defects  of  mucous 
surfaces  accessible  to  direct  treatment  holds  out  many  inducements  for 
future  imitation.  The  difficulties  in  the  way  of  equal  uniform  success 
in  the  transplantation  of  grafts  of  mucous  membrane,  as  in  skin  trans- 
plantation, are  owing  to  the  location  of  the  seat  of  operation.  In  the 
former  instance  it  must  always  be  such  as  to  preclude  the  possibility  of 
securing  perfect  asepsis  on  the  one  hand,  and  the  impossibility  of  apply- 
ing an  efficient  protective  dressing ;  at  the  same  time,  it  is  also  more 
difficult  to  obtain  the  proper  material  for  the  grafting. 

CONNECTIVE    TISSUE. 

The  granulations  seen  upon  a  wound  or  ulcerating  surface  are 
formed  almost  exclusivel}^  by  the  transformation  of  mature  connective 
tissue  into  embryonal  tissue,  the  cellular  elements  of  which  they  are 
I'omposed  being  embryonal  connective-tissue  cells.  This  transition  of 
mature  into  embryonal  cells  is  accomplished  by  karyokinesis.  As  con- 
nective tissue  is  found  almost  in  every  part  and  organ  of  the  body,  it 
takes  an  active  part  in  the  repair  of  all  wounds,  and  when  the  more  im- 
])ortant  tissues  in  the  wound  cannot  be  approximated  for  organic  union 
to  take  place  its  greater  vegetative  capacity  enables  it  to  produce  a  large 
amount  of  new  material,  which  later  forms  a  connecting  bridge  of  cica- 
tricial tissue.  For  instance,  in  a  transverse  wound  of  a  muscle,  where  it 
is  often  difficult,  if  not  impossible,  to  keep  the  divided  ends  sufficiently 
npproximated  for  the  wound  to  heal  by  the  interposition  of  new  muscle- 
cells,  the  gap  is  spanned  by  a  band  of  connective  tissue,  wliieli,  if  not 


42  PRINCIPLES   OF    SURGERY. 

completel}^  at  least  partially,  restores  the  function  of  the  muscle  by  fur- 
nishing it  with  two  additional  fixed  points  of  attachment.  Graser  has 
shown  that  the  first  karyokinetic  changes  are  seen  in  connective-tissue 
cells  some  distance  from  tlie  surface  of  the  wound,  and  that  the  new  cells 
reach  the  surface  with  the  new  blood-vessels,  where  they  constitute  the 
granulation  tissue.  In  aseptic  wounds,  where  cicatrization  progresses 
rapidlj',  the  embryonal  connective-tissue  cells,  or  granulation  cells,  are 
short-lived,  as  they  are  rapidly-  transformed  into  mature  connective  tissue, 
which  here  constitutes  the  cicatrix.  In  suppurating  wounds,  the  super- 
ficial layer  of  embryonal  cells  are  brought  in  contact  with  the  pus- 
microbes  and  their  ptomaines,  which  destroy  the  protoplasm  of  the  cells, 
when  they  are  transformed  into  pus-corpuscles ;  while  those  nearer  the 
blood-vessels  retain  their  vitalit}'  and  capacity  of  undergoing  cicatrization. 

BLOOD-VESSELS. 

Wounds  of  large  blood-vessels,  with  few  exceptions,  require  such 
measures  in  their  treatment  which  completely  arrest  the  circulation,  and 
which  .aim  at  permanent  obliteration  of  the  lumen  by  the  usual  method 
of  cell  proliferation  and  cicatrization.  A  wound  of  an  arter}^  if  accessi- 
ble to  direct  treatment,  should  be  treated  by  cutting  the  vessel  completely 
across  and  applying  a  ligature  to  each  end.  A  small  wound  of  a  large 
vein  can  be  treated  successfull}^  under  favorable  conditions,  b}^  closing 
it  with  a  lateral  ligature.  With  a  tenaculum  the  margins  of  the  wound 
are  transfixed,  and  by  making  slight  traction  the  vein-wall  is  raised,  and 
around  the  base  of  the  little  cone  thus  formed  a  fine  catgut  ligature  is 
applied.  If  the  wound  remains  aseptic,  the  mural  thrombosis  at  the  seat 
of  ligation  is  slight,  and  closure  of  the  wound  is  effected  without  oblitera- 
tion of  the  lumen  of  the  vessel.  A  wound  of  a  blood-vessel  usually 
terminates,  spontaneously  or  through  the  intervention  of  art,  in  perma- 
nent interruption  of  the  circulation  b}'  the  formation  of  an  intra-vascular 
cicatrix.  For  many  years  it  has  been  maintained  that  obliteration  of  a 
vessel  after  injury,  disease,  or  ligature  resulted  from  what  was  termed 
"  organization  of  the  thrombus."  It  was  believed  that  the  thrombus  be- 
came vascular  eitlier  from  the  lumen  of  the  vessel  or  the  vasa  vasorum, 
and  that  the  histological  elements  in  the  thrombus  took  an  active  part 
in  the  production  of  tlie  intra-vascular  cicatrix.  Numerous  experimental 
investigations  by  difterent  authors,  undertaken  for  the  purpose  of  demon- 
strating that  in  wounds  of  blood-vessels  healing  takes  place  in  the  same 
manner  as  in  the  wounds  of  other  tissues,  have  shown  that  the  blood-clot 
always  occupies  only  a  passive  role,  and,  if  present,  is  only  in  tlie  way 
of  a  speed}'  definitive  closure,  which  invariably  is  effected  by  prolifera- 
tion from  the  fixed  cells  of  the  vessel-wall.     Eliminating  the  thrombus 


BLOOD-VESSELS. 


43 


as  an  active  agent  in  the  obliterating  process,  we  can  say  that  union  be- 
tween the  tissues  which  are  brought  in  contact  by  the  ligature  takes 
place  by  tissue  proliferation  from  the  walls  of  the  vessel  itself.  In  the 
true  sense  of  the  word,  direct  or  immediate  union  is  as  impossible  here 
as  in  any  other  wound,  and,  hke  everywhere  else,  the  intra-vascular  cica- 
trix is  formed  from  tissue  derived  from  the  tissue  of  the  injured  vessel- 
wall.  In  case  the  inner  tunics  are  severed  by  the  ligature,  the  lacerated 
surfaces  are  brought  in  contact  with  the  adventitia,  and  repair  takes 
place  as  in  other  tissues  which  are  largely  composed  of  connective  tissue, 
the  process  extending  from  both  sides  of  the  ligature,  where  endothelia 


Vasa  vasorum. 


Intima. 


Partly-formed  connective 
tissue  from  endothelia. 


Proliferated 
connective 
tissue  in 
lumen. 


Endothelial  ^_ ^ 

proliferation.    ^-"^ , 


Fio.  21.— MiCROscopicAii  Appkaraxofs  of  the  Interiok  of  Aktery  of 
Dog  Forty-nine  Days  aftek  Ligation.  Transverse  Section 
THROUGH  Border  of  Artery,    x  240. 

assist  in  the  process  of  cicatrization.  If,  on  the  other  hand,  the  con- 
tinuity of  the  vessel  is  not  destroyed  by  the  ligature,  and  the  intima  is 
simply  brought  in  contact  without  being  ruptured,  the  new  cells  from  the 
connective  tissue  perforate  the  endothelial  lining,  and  the  new  elements 
of  the  latter  join  in  the  reparative  process  by  being  converted  fi'om  their 
embryonal  state  into  connective  tissue.  The  histological  changes  in  the 
interior  of  veins  undergoing  oV)literation  are  the  same  as  in  arteries,  the 
new  material  of  which  the  cicatrix  is  composed  being  derived  exclusively 
from  the  endothelial  and  connective-tissue  cells. 


44 


PRINCIPLES    OF    SURGERY. 


J.  Collins  Warren,  who  li:is  done  excellent  work  in  studying  experi- 
mentiilly  the  healing  of  arteries  after  ligature,  niaiutains  that  he  has  seen 
sulfieieut  evidence  in  his  specimens  tliat  the  muscle-cells  in  the  tunica 
media  take  au  active  part  in  the  process  of  rejjair.  The  same  author 
compares  tlie  process  of  healing  in  arteries  to  the  formation  of  callus  after 
fracture,  and  hence  calls  tlie  intra-vascular  material  the  internal  and  the 
extra-vascular  the  external  callus.  The  numerous  experiments  of  the 
author  on  ligation  of  arteries  and  veins  have  demonstrated,  to  his  own 
satisfaction,  that  the  most  speedy  obliteration  of  a  vessel  is  obtained  if 


Proliferation 
of  connective 
tissue. 


Fig.  22.— Microscopical  Appearances  op  the  Interior  of  Vein  of  Dog 
Forty-nine  D.vys  after  Ligation.  Transverse  Section  of  Part  of 
Vein  in  Ligateb  Portion.    X  240. 


the  vessel  is  rendered  bloodless  by  the  application  of  two  ligatures.  The 
ligatures  are  applied  with  sufficient  firmness  to  obliterate  the  lumen  of 
the  vessel  without  rupturing  any  of  its  coats.  After  ligation  the  walls 
of  the  vessel  became  thickened  so  that,  a  few  weeks  after  the  ligatures 
had  been  applied,  the  vessel  presented  a  spindle  shape,  tapering  toward 
each  side,  a  condition  entirely  due  to  the  formation  of  new  material, — 
the  external  callus  of  Warren.  The  bloodless  space  between  the  ligatures 
is  obliterated  in  a  short  time  b3'  cells  which  enter  it  from  the  vessel-wall. 
In  the  obliteration  of  A^eins  nnd  ligation  of  arteries  in  their  con- 
tinuitj^  the  double  ligature,  including  a  bloodless  space  about  ^  inch  in 


BLOOD-VESSELS.  45 

length,  places  the  tissues  in  the  most  ftivorablc  conditions  for  speed}'- 
definitive  closure  by  an  intra-vascular  cicatrix.  When  the  vessel  is  ex- 
posed catgut  should  be  used,  but  in  the  subcutaneous  ligation  of  veins 
silk  is  preferable.  Since  the  introduction  of  antiseptic  surger}'  and  tlie 
aseptic  ligature,  seeoiulary  haemorrhage  has  become  an  exceedingl}-  rare 
accident,  and,  when  it  does  occur,  it  is  in  wounds  where  the  antiseptic 
measures  have  failed.  A  vessel  in  an  aseptic  wound,  tied  with  an  aseptic 
ligature,  becomes  in  a  few  hours  the  seat  of  a  regenerative  process  which 
eftectuall}'  guards  against  the  possibility  of  hnpuiorrhage,  even  if  the 
mechanical  obstruction  caused  by  the  ligature  should  be  removed  after  a 
few  daj's.  The  aseptic  ligature,  applied  under  strict  antiseptic  precau- 
tions, has  been  advantageous  in  other  directions.  The  older  surgeons 
alwa3'S  expected,  after  ligating  an  arterj-  in  its  continuit}',  that  the 
thrombus  would  extend  on  the  proximal  side  to  the  nearest  collateral 
branch,  and  on  this  account  the}-  were  always  anxious  to  secure  a  space 
of  an  inch  or  more  between  the  ligature  and  the  nearest  large  collateral 


Fig.  23.— FEMORAii  Artery  of  Dog  Fifty  Days  after  Double  Ligation 
WITH  Silk.  Below,  Transverse  Section  showing  Bloodless  Space 
Filled  with  Cicatricial  Material.    (Xatural  Size.) 

branch,  in  order  to  prevent  secondarj-  hferaorrhage.  The  aseptic  ligature 
is  never  followed  by  such  extensive  thrombosis,  and  the  intra-vascular 
cicatrix  is  often  exceedingl}-  narrow, — in  fact,  almost  linear.  The  limited 
thrombosis  and  the  prompt  formation  of  an  intra-vascular  cicatrix  place 
the  surgeon  now  in  a  position  that  he  can  ligate  a  large  arter^',  close  to  a 
collateral  branch  or  near  a  point  of  bifurcation,  without  a  particle  of  fear 
of  incurring  secondary  haemorrhage.  In  the  ligation  of  veins  the  aseptic 
ligature  has  dispersed  all  fear  of  suppurative  thrombo-phlebitis  and 
pyaemia, — complications  which  were  formerly  so  much  feared,  even  after 
insignificant  operations  on  veins.  In  the  repair  of  wounds  union  between 
the  divided  ends  of  blood-vessels  is  probabl}'  never  effected.  The  vessel- 
ends  are  temporaril}-  closed  either  b}^  t^ing  with  a  ligature  or  by  the 
formation  of  a  thrombus,  the  former  being  the  case  when  vessels  of  some 
size  have  been  divided,  the  latter  being  accomplished  usually  spontane- 
ously in  vessels  which  give  rise  to  parenchjmatous  haemorrhage.  In 
either  instance  the  ends  of  the  vessel  are,  later,  permanently  sealed  b}'  the 
formation  of  a  cicatrix  by  proliferation  of  fixed  tissue-cells,  the  endo- 


46  PRINCIPLES   OF    SURGERY. 

ihelia,  and  connective-tissue  cells.  The  interrupted  circulation  between 
the  two  sides  of  the  wound  is  restored  indirectly  through  collateral 
branches,  which  are  always  new  blood-vessels.  The  angioblasts  in  the 
injured  capillary  vessels  assume  active  tissue  proliferation  within  twenty- 
four  hours  after  the  injury  has  occurred,  and  through  them,  almost  exclu- 
sively, the  new  blood-vessels  are  formed  in  the  shape  of  loops,  which, 
coming  as  they  do  from  both  sides,  establish  the  vascular  connection 
between  the  two  surfaces  of  the  wound.  Man}'  of  these  new  blood-vessels 
disappear  after  the  consummation  of  the  reparative  process,  while  others 
remain  as  permanent  collateral  vessels  between  the  closed  ends  of  the 
old  blood-vessels  permanently  separated  by  the  injur3\ 

MUSCLES. 

It  is  only  quite  recently  that  it  has  been  ascertained  that  a  divided 
muscle  can  unite,  under  favorable  circumstances,  by  interposition  of  new 
muscular  tissue  between  the  divided  ends.  It  was  formerly  believed 
that  healing  was  alwaj's  accomplished  by  the  formation  of  connective 
tissue,  and  that  the  ends  of  the  cut  muscle  remained  permanently  sepa- 
rated by  a  bridge  of  cicatricial  tissue.  The  theory  that  connective  tissue 
can  be  transformed  into  muscular  tissue  is  untenable,  since  Pflueger  has 
demonstrated  the  minute  structure  of  muscular  fibre.  Kolliker  has 
shown  that  the  fibrillse  in  the  muscle-fibre  constitute  the  real  ground- 
substance.  Rabl  ascertained,  by  his  eml)ryological  researches,  that  the 
muscular  tissue  is  derived  from  a  distinct  portion  of  the  mesoblast,  and 
consequently  proved  that  at  a  very  early  period  of  embryonal  life  an 
absolute  difference  takes  place  between  muscular  and  connective  tissue. 
Heterotopic  muscular  structures  must,  therefore,  be  looked  upon,  not  as 
products  of  connective-tissue  proliferation,  but  as  a  growth  from  a  dis- 
placed embr^'onal  matrix  of  muscular  tissue. 

The  vegetative  capacity  of  muscle-cells,  striped  and  unstriped,  is 
quite  limited,  as  compared  with  some  of  the  other  tissues,  so  that  if  the 
ends  of  a  muscle  that  lias  been  cut  transverselj'  are  separated  for  more 
than  an  inch  complete  restoration  of  the  continuity  of  the  muscle  is  not 
attaind,  and  the  two  ends  are  connected  b}-  a  band  of  connective  tissue. 
If,  during  the  healing  of  the  wound,  the  cut  surfaces  of  the  muscle  are 
kept  in  accurate  contact,  and  even  if  a  gap  of  half  an  inch  exist  between 
them,  restoration  ad  integrum  takes  place  b}'  proliferation  of  the  muscle- 
elements  near  the  seat  of  injury. 

Non-striated  Muscular  Fibre. — Stilling  and  Pfitzner,  as  well  as 
Busachi,  have  shown  that  unstriped  muscular  fibres  multiply  b^y  indirect 
division  of  their  nuclei,  and  in  the  repair  of  wounds  of  this  tissue  new 
fibres  are  produced  exclusivel}'  b^'  this  method.     These  authors  studied 


MtrscLES.  47 

the  karyokin»tic  changes  in  the  muscular  fibres  of  the  triton  tseniatus. 
They  observed,  after  the  division  of  the  nucleus  in  the  usual  manner  by 
karyokinesis,  that  as  the  new  nuclei  separated  and  approached  the  poles 
of  the  cell  the  protoplasm  of  the  cell-body  at  the  transverse  axis  became 
narrower,  showing  a  well-marked  constriction,  which  would  indicate  that 
subsequently  cell-division  occurred.  Herczel  witnessed  similar  changes 
in  the  hypertrophic  muscular  coat  of  the  intestines  on  the  proximal  side 
of  strictures.  In  defects  caused  by  the  injury,  removal,  or  destruction 
of  unstriped  muscular  fibres,  regeneration  takes  place  only  from  the 
margins,  wliile  the  centre  at  first  is  occupied  by  connective  tissue.  The 
new  muscular  fibres  are  at  first  irregularly  arranged,  and  it  is  only 
toward  the  completion  of  the  healing  process  that  the  new  tissue  repre- 
sents to  perfection  the  mature  muscular  fibres.  Klebs  is  of  the  opinion 
that  the  leucocytes  serve  as  food  for  the  cells  which  undergo  karj-okinetic 
changes. 

Striated  Muscular  Fibre. — 0.  Weber,  as  early  as  1854,  claimed  that 
in  the  healing  of  wounds  new  muscular  fibres  are  produced,  but,  in  accord- 
ance with  the  views  which  then  prevailed,  believed  they  were  derived 
from  connective  tissue.  Wittich  saw,  in  hibernating  frogs,  new  fibres 
which  he  believed  had  developed  from  the  cells  of  the  internal  peri- 
mysium. In  1865,  after  an  examination  of  a  genuine  myoma  strio- 
cellulare,  Buhl  expressed  the  opinion  that  new  muscular  fibres  are 
produced  from  old  fibres.  In  tlie  same  year  Walde^'er  discovered  the 
muscle-cell  sheath,  and  he  regarded  the  cell  inclosed  by  it  as  a  derivative 
of  the  nucleus  of  the  fibre,  but,  Avitli  Zenker  and  others,  he  still  regarded 
the  perimysium  as  the  source  of  new  muscular  fibres.  In  1868  E. 
Neumann  made  the  observation  that  after  section  or  laceration  of  a 
muscle  the  ends  of  the  fibres  became  the  seat  of  active  tissue  changes, 
which  resulted  in  the  formation  of  what  he  termed  muscle-buds.  These 
muscle-buds  were  not  only  found  at  the  ends  of  the  fibres,  but  also  on 
their  sides;  at  first  they  were  seen  to  be  composed  of  numerous  nuclei 
and  protoplasm,  while  later  they  were  transformed  into  striated  fibres. 
The  sarcolemma  is  such  a  delicate  structure  that  new  cells  which  form 
within  it  readily  find  their  way  through  it,  and  appear  upon  its  outer 
surface  in  the  shape  of  buds,  as  described  by  Neumann. 

Tizzoni  has  recently  investigated  the  karyokinetic  changes  in  the 
nuclei  or  sarcoblasts  in  the  perim^^sium  during  the  repair  of  muscle 
wounds.  The  first  evidences  of  cell  proliferation  were  seen  in  the  nuclei 
or  myoblasts  nearest  tlie  seat  of  injury,  and  proliferation  took  place  in 
fibres  which  had  undergone  degeneration  as  well  as  in  those  which  pre- 
sented a  striated  appearance.  Leven  found,  during  the  first  twenty-four 
hours  after  injury,  an  increase  of  nuclei  of  the  sarcolemma  sheath.    These 


48 


PRINCIPLES   OF    SURGERY. 


new  nuclei  are  arranu^ed  in  the  form  of  rows  and  heaps,  and  by  mutual 
pressure  are  flattened.  Many  of  tliese  new  elements  present  karyokinetic 
figures,  and  around  them  i)rotoplasm  is  deposited,  and  tlie  new  cells 
become  spindle-shaped.  The  new  cells  increase  in  number  from  the  third 
to  the  fourth  day,  so  that  at  this  time  from  five  to  six  can  be  seen  under 
one  field.  Klebs  studied  regeneration  of  muscle  in  young  guinea-pigs 
after  puncturing  subcutaueously  the  gastrocnemius  muscle.  He  came  to 
the  following  conclusions:  A  portion  of  the  muscular  fibres  die  and 
shrink,  and  in  this  condition  the_y  can  be  stained  more  deeply  with 
hpematoxylin  than  the  others.  Such  fibres  are  completely  removed  by 
absorption  within  the  first  four  davs.     In  the  fibres  which  remain  striated 


Fig.  24.— Muscular  Fibres  Near  a  Wound  in  a  State  of  Proliferation. 

(O.  Weber). 

A,  contused  end  of  muscular  fibre  ;  B,  muscular  fibre  retracted  within  sarcolemma,  the  latter 
terminating  in  a  sharp  point;  C,  old  fibre  degenerated  into  a  colloid  mass;  D,  young  nuclei  between 
and  upon  fibres;  E,  nuclei  surrounded  by  cell-protoplasm;  F,  new  cell,  showing  scriations ;  G,  new 
muscular  fibre. 


the  fibrilloe  become  plainer,  and  in  them  the  regenerative  process  can  be 
distinctly  seen.  The  nuclei  increase  in  number,  and  are  packed  densely 
together,  but  at  this  stage  he  was  unable  to  detect  any  evidences  of 
karyokinesis.  During  this  stage  Steudel  was  also  unable  to  detect  any 
appearances  which  indicated  indirect  cell  division.  These  3''oung  cells  are 
called  sarcoblasts  by  Klebs,  and  their  transformation  into  muscle-fibres 
is  effected  by  aggregation  around  them  of  a  very  thin  layer  of  proto- 
plasm. The  youngest  cells  are  round,  and  the  change  into  spindle  form 
is  o-radual.  The  new  cells  nre  nrrano^ed  in  rows  between  the  old  muscular 
fibre  (Fig.  24,  between  G  and  B).  Some  authors  believe  that  the  sarco- 
blasts unite  end  to  end,  and  that  the  muscular  fibre  is  formed  in  this 


BONE.  49 

manner.  Kraske  and  Klebs  maintain  that  muscular  fibres  result  from  a 
single  cell  by  gradual  elongation  of  the  cell-bodj'.  In  the  regeneration 
of  the  muscular  fibres  of  the  heart  after  injur}',  Martinti  and  Bonome 
witnessed  karj'omitotic  changes  in  the  interior  of  the  sheath  of  numerous 
fibres,  while  in  others  where  degenerative  changes  had  taken  place  no 
such  changes  could  be  seen.  In  wounds  of  the  heart  of  old  rats  karj'o- 
mitosis  commences  five  to  six  days  after  the  injur}',  and  does  not  last 
longer  than  six  to  seven  daj's,  and  results  onl}^  in  incomplete  regener- 
ation. In  myocarditis  tlie  formation  of  new  muscular  fibres  has  been 
observed  by  Virchow,  Boettcher,  and  Waldeyer. 

Muscle  Suture. — In  the  treatment  of  recent  wounds  special  pains 
should  be  taken  to  secure  accurate  approximation  between  the  ends  of 
divided  muscles.  For  this  purpose  special  means  must  be  employed 
when  large  muscles  have  been  divided  transversely.  In  sucli  cases  the 
retraction  which  follows  gives  rise  to  great  separation,  which  can  only 
be  overcome  by  suturing  respective  ends  separately  with  l)iiried  animal 
sutures.  Great  care  is  necessary  not  to  invert  the  margins,  but  to  unite 
the  cut  surfaces  throughout,usingfor  this  purpose,  if  necessary,  as  many 
as  six  sutures,  which  must  include  considerable  tissue  in  order  to  prevent 
their  tearing  through.  In  muscles  supplied  with  a  well-marked  sheath 
this  should  be  sutured  separatel3\  In  the  after-treatment  it  is  necessary 
to  place  the  limb  in  such  a  position  that  will  relax  the  sutured  muscles, 
and  to  secure  immobility  of  the  limb  in  this  position  b}^  a  proper  me- 
chanical support,  which  should  not  be  removed  until  the  healing  process 
is  completed,  in  order  to  prevent  subsequent  diastasis  between  the 
sutured  ends.  When  it  is  desirable  to  elongate  a  contracted  muscle  in 
the  correction  of  deformities,  as  in  the  treatment  of  torticollis,  the  con- 
tracted muscle  should  be  exposed  by  incision,  and  after  section  a  suture 
a  distance  is  applied.  A  number  of  heavy  catgut  sutures  will  answer  an 
excellent  purpose,  as  they  will  maintain  fixation  of  the  separated  ends 
in  a  desirable  position,  and  will  furnish  an  admirable  scaffolding  for  the 
new  connective-tissue  cells,  which,  later  on,  are  transformed  into  a  tendon 
which  permanently  connects  the  retracted  ends  of  the  divided  muscle. 

BONE. 

The  granulation  material  by  which  the  fractured  bone  unites  is  called 
callus.  According  to  the  location  of  this  material  around,  within,  or  be- 
tween the  fragments,  we  speak  of  an  external,  internal,  or  intermediate 
callus.  The  external  or  provisional  callus  is  abundant,  as  a  rule,  where 
the  broken  bone  is  surrounded  b3'a  thick  cushion  of  soft  parts,  and  when 
the  fragments  are  not  well  immobilized.  It  forms  early  and  disappears 
gradually  after  the  fracture  has  united.    The  internal  or  medullary  callus, 


50  PRINCIPLES   OF    SURGERY. 

which  takes  the  place  of  the  medunary  tissue  in  fractures  of  the  shaft  of 
tlie  long  bones,  serves  a  useful  purpose  as  a  means  of  fixation  of  the 
fragments,  and  is  also  removed  in  the  course  of  time  after  union  has 
taken  place,  and  with  its  disappearance  the  medullary  cavity  is  restored. 
The  intermediate  or  definitive  callus  is  the  material  interposed  between 
the  broken  surfaces,  and  which  is  transformed  into  permanent  tissue. 
Callus  is  the  product  of  cell  proliferation  of  those  tissue-elements  which 
are  directly  concerned  in  the  growth  and  development  of  bone. 

Duhamel  de  Monceau  attributed  to  the  periosteum  and  endosteum 
the  function  of  producing  callus.  Haller  and  his  prosector,  Detlef,  be- 
lieved that  the  periosteum  takes  no  part  in  the  regeneration  of  bone,  but 
that  callus  is  derived  from  the  fractured  ends  of  the  bone,  more  especially 
the  myeloid  tissue.  Dupuytren  maintained  that  the  periosteum  and  the 
paraperiosteal  connective  tissue  were  bone-producing  tissues.  Cruveil- 
hier  claimed  that  the  lacerated  soft  tissues  around  the  fractured  bone- 
ends,  the  periosteum,  connective  tissue,  muscles,  tendons,  etc.,  furnished 
the  material  for  the  callus. 

Flourens  claimed  that  the  periosteum  alone  could  produce  new  bone. 
Rokitansky  asserted  that  callus  is  developed  directly  from  bone  and  its 
connective  tissue,  including  the  periosteum.  From  his  own  experimental 
work,  R.  Hein  came  to  the  conclusion  that  regeneration  of  bone  takes 
place  from  connective  tissue  in  and  around  bone  and  the  periosteum. 
According  to  Virchow,  callus  is  produced  from  connective  tissue  outside 
of  the  bone,  as  well  as  from  the  medullary  tissue.  Hofmokl  con- 
sidered as  sources  of  callus  formation  the  periosteum,  bone,  and  mar- 
row. Gegenbauer  takes  the  ground  that  bone  is  produced  directly  from 
connective  tissue.  He  asserts  that  Sharpey's  fibres,  if  traced  carefully, 
can  be  seen  springing  from  a  bony  point  between  the  Haversian  canals, 
from  which  point  they  radiate  toward  both  sides  into  the  lamellar  sys- 
tems. The  fibres  form  net-works,  and  at  points  of  intersection  bone- 
cells  are  produced,  and  a  deposit  of  lamellae  takes  place  around  the 
connective-tissue  fibres. 

It  is  now  generally  conceded  that  the  provisional  callus  is  the  prod- 
uct of  tissue  proliferation  from  the  periosteum,  while  the  definitive  or 
permanent  callus  is  produced  directly  from  the  medullary  tissue.  The 
provisional  callus  is  nature's  splint,  its  onl}'  object  being  to  immobilize 
the  parts  until  the  definitive  callus  firmly  and  permanently  unites  the 
fragments.  The  temporarj'  callus  is  an  accidental  product,  and  appears 
earliest  and  most  copiously  where  the  paraperiosteal  tissues  are  most 
abundant  and  motion  between  the  fragments  greatest ;  the  intermediate 
or  permanent  callus  is  produced  later, and  is  transformed  into  permanent 
tissue.     Oilier  and  Buchholtz,  in  their  experiments  on  transplantation  of 


BONE. 


51 


periosteum,  found  that  the  transplanted  tissue  first  produced  cartilage, 
which  later  was  transformed  into'  bone ;  but  they  also  ascertained  that 
such  bone  disappeared  again  unless  it  formed  in  a  place  where  bone  nor- 
mall}^  exists.  Cohnheim  and  Maas  came  to  the  same  conclusion  from  their 
experiments  on  intra-venous  transplantation  of  periosteal  grafts.  It  is 
possible  that  special  cells  (Mastzellen)  are  the  active  agents  in  the 
removal  of  tissue  in    places  where  it   has  no  physiological   existence. 


—  A 


Fig.  25.— Section  through  Callus  Fifty-two  Hours  after  Fracture  of  Ulna 
FROM  Rabbit.    Beginning  Formation  of  osteoid  Tissue.    (Bajardi.) 

A,  cortical  portion  of  bone;   B,  osteoid  tissue;  C,  beginning  of  formation  of  a  lamella,  surrounded  by 
osteoblasts;  D,  periosteum.    (Hartnack,  Obj.  8.) 

Macewen  has  maintained  for  years  that  bone  grows  only  from  bone,  and 
the  results  obtained  by  applying  this  principle  in  practice  speaks 
strongly  in  favor  of  this  supposition.  That  medullary  tissue  alone  can 
produce  bone  has  been  experimental!}'  demonstrated  by  Burns.  The 
osteoblasts  from  which  bone  production  alone  can  take  place  are  foimd 
in  the  periosteum,  more  especially  its  inner  layer,  the  cambium,  and  in 
the  interior  of  bone.  Regeneration  of  bone  from  these  cells  takes  place 
in  two  ways, — either  the  cells  are  transformed  into  an  osteoid  tissue,  or 


52 


PRINCIPLES   OF   SURGERY. 


they  are  first  changed  into  cartilage-cells,  and  the  latter  at  a  later  stage 
undergo  ossification.  The  osteoblasts  in  the  periosteum,  and,  to  a  lesser 
extent,  those  in  the  central  medullar}^  cavity,  produce  bone  by  this  indi- 
rect method,  while  in  other  places  ossification  is  effected  in  a  more  direct 
wa}'  by  the  osteoblasts  being  transformed  into  an  osteoid  substance. 

In  the  normal  regeneration  of  bone,  cartilage  pla3's  an  important  part. 
As  the  bone-cells  disappear,  or  at  least  lose  their  nuclei  where  cartilage- 
cells  form,  it  is  probable  that  the  cartilage-cells  represent  structures  in- 
termediate between  osteoblasts  and  bone-colls.     Cartilage  is  abundant 

R       .R 
/       /        

^_  _i P 

Fig.  26.— Transverse  Section  through  Callus  of  Tibia  of  Rabbit  Forty  Days 
AFTER  Fracture,  with  External  Resorption.    (Muas.) 

P,  periosteum,  much  thickenad ;  R,  giant  cells  or  osteoklasts ;  G,  blood-vassels ;  M,  medullary  resorption 
spaces  ;  K,  compact  portion  of  bone. 

where  union  is  retarded,  and  especiall}^  in  cases  of  pseudarthrosis. 
During  ossification  the  h3-aline  cement-substance  between  the  cartilage- 
cells  is  dissolved,  and  the  space  gives  way  to  lamellae,  while  the  cells  are 
transformed  into  bone-cells.  According  to  Krafft,  multiplication  of  the 
bone-producing  cells  of  the  periosteum  can  be  seen  twenty  to  thirty 
hours  after  fracture,  in  the  shape  of  karyokinetic  figures  in  the  nuclei  of 
the  cells,  while  somewhat  later  the  same  figures  are  to  be  seen  in  the 
endothelia  lining  the  blood-vessels.  The  new  cartilage-cells  also 
multiply  by  karyokinesis.  Like  in  the  healing  of  wounds  in  soft  parts, 
the  cells  on  the  surface  of  the  fracture  take  no  part  in  the  process  of 


BONE.  53 

regeneration,  as  their  proliferation  capacity  has  been  destroyed  by  the 
trauma  as  well  as  the  sudden  diminution  of  the  vascular  supply.  Osteo- 
porosis at  the  seat  of  regeneration  is  alwaj-s  present,  and  results  from 
the  action  of  another  kind  of  cells  discovered  by  KoUiker, — the  osteo- 
klasts.  Robin  described  them  as  myeloplaques.  The}^  are  found  in 
Howship's  lacunae  where  resorption  takes  place. 

The  osteoklasts  appear  to  be  nothing  else  but  myeloid  cells  which 
have  lost  their  bone-producing  function  ;  they  are  in  reality  hyperplastic 
osteoblasts.  Absorption  of  bone  takes  place  because  these  cells  do  not 
produce  bone.  There  is  no  reason  to  believe  that  these  cells  are  altered 
bone-cells,  as  no  intermediate  forms  have  been  found.  Ziegler  does  not 
assign  much  influence  to  these  cells  in  the  resorption  of  bone.  Wegner 
has  shown  that  in  pathological  processes  in  bone  where  resorption  takes 
place  they  are  arranged  along  the  sides  of  blood-vessels,  and  on  this 
account  he  believed  they  were  derived  from  the  A'essel-wall.  Klebs  is  of 
the  opinion  that  the  osteoklasts  ma}-  secrete  a  chemical  substance  which 
decalcifies  the  bone.  Resorption  of  superfluous  callus  is  accomplished 
undoubtedly  bj^  the  action  of  osteoklasts,  an  exceedingly  useful  function, 
as  b}'  it  form  and  strength  of  the  broken  bone  are  restored. 

According  to  Mejer  the  architectural  structure  of  the  spongiosa, 
after  the  healing  of  a  fracture,  adapts  itself  to  the  new  conditions,  so 
that  the  new  traction  and  pressure-curves  are  arranged  in  such  a  manner 
as  will  resist  the  greatest  degree  of  force.  This  capacit}'  of  adaptation 
is  present  to  a  very  high  degree  in  bone. 

Abnormal  and  Defective  Callus. — Callus  may  be  formed  in  excess  of 
local  requirements  after  a  fracture,  and  yet  no  union  take  place.  The 
osteoblasts  respond  promptly  to  the  stimulus  created  b}'  the  trauma, 
karyokinetic  changes  occur  early,  new  cells  are  formed  with  great 
rapidity,  and  a  large  mass  of  new  material  is  deposited  at  the  seat  of 
fracture,  but  bon}-  consolidation  does  not  occur  because  the  new  tissue 
does  not  undergo  ossification.  The  normal  development  of  cells  is 
arrested  at  an  early  stage,  and  the  chemical  process  upon  which  ossifica- 
tion depends  are  delayed  or  fail  to  appear  altogether.  Prompt  bony 
union  does  not  only  imply  that  the  osteoblasts  at  the  seat  of  fracture 
should  undergo  karA^okinetic  changes  and  multiply,  but  that  the  new 
tissue  must  be  placed  under  the  influence  of  favorable  chemical  conditions 
which  will  enable  it  to  be  transformed  into  bone. 

A  few  years  ago  B.  von  Langenbeck  reported  2  cases  of  fracture  of 
the  femur,  where  he  resorted  to  amputation  of  the  thigh  under  the  belief 
that  tlie  luxuriant  callus,  which  formed  in  each  case  at  the  seat  of 
fracture,  was  a  sarcoma.  Microscopical  examination  in  both  instances 
showed  that  the  swelling  was  composed  of  cells  which  are  found  in  callus 


54  PRINCIPLES   OF   SURGERY. 

5it  nil  early  stage  of  its  formation,  witliout  any  evidences  of  ossification 
of  tiie  new  material.  The  causes  of  delayed  ossification  are  not  known, 
but,  as  in  a  number  of  instances  of  profuse  callus  formation  and  delayed 
union  a  vigorous  antisyphilitic  course  of  treatment  produced  favorable 
results,  it  appears  that  the  virus  of  syphilis  may  at  least  be  one  of  them. 
We  know  that  in  gummata  the  same  conditions  prevail  in  the  persistence 
of  tissue  in  its  embryonal  state  for  an  indefinite  period  of  time,  or  until 
the  syphilitic  virus  has  been  removed  or  neutralized  by  proper  anti- 
syphilitic  treatment. 

In  cases  where  no  such  cause  for  the  delay  of  the  transition  of  callus 
into  bone  can  be  surmised,  the  internal  administration  of  minute  doses 
of  phosphorus  should  be  tried.  Kassowitz  produced  osteoporosis  in 
animals  experimentally  by  large  doses  of  phosphorus,  while  minute 
doses  produced  an  opposite  effect.  He  recommended  the  remedy  in 
small  doses  in  the  treatment  of  rickets,  and  since  then  it  has  been  ex- 
tensively used  in  the  treatment  of  this  disease,  and  with  the  best  results. 
The  action  of  this  drug  undoubtedly  would  produce  a  favorable  effect 
upon  the  osteoid  material,  in  hastening  its  transition  from  the  embryonal 
into  a  mature  state.  Defective  callus  formation  will  necessarily  follow  a 
fracture  if  the  osteoblasts  fail  to  enter  upon  an  active  process  of  cell 
proliferation.  These  are  the  cases  where  the  surgeon  resorts  to  local 
measures,  which  are  intended  to  stimulate  the  cells  to  increased  activity. 
Fractures  of  the  lower  extremities  which  have  failed  to  unite  as  long  as 
the  patient  is  kept  in  bed  often  unite  promptly  after  he  is  allowed  to 
walk  around  on  crutches,  the  favorable  change  being  brought  about  by 
an  increased  blood-supply  to  the  seat  of  fracture. 

Dumreicher  suggested  that  the  local  blood-supply  could  be  increased 
by  applying  a  compress  and  bandage  above  and  below  the  seat  of  fracture, 
while  Helferich  more  recently,  and  with  the  same  object  in  view,  advised 
moderate  constriction  with  an  elastic  bandage  applied  in  such  a  manner 
as  not  to  interfere  with  the  arterial  circulation.  Rubbing  of  the  frag- 
ments forcibly  against  each  other  is  an  old  method  of  treating  delaj^ed 
union,  and  has  often  been  sufficient  to  rouse  the  dormant  osteoblasts 
into  active  cell  proliferation.  The  distinguished  Brainard  made  the 
treatment  of  delayed  union  a  special  study  during  many  years  of  his 
useful  life,  and  devised  a  new  method  of  treatment,  the  subcutaneous 
drilling  of  the  ends  of  the  fragments,  which  has  been  extensively  prac- 
ticed, and  has  yielded  most  excellent  results.  The  drilling  of  the  ends 
of  the  broken  bone  has  a  most  decided  effect  in  stimulating  the  sluggish 
separative  process,  as  it  produces  osteoporosis  and  increases  the  vascu- 
larit}'  of  the  parts,  both  of  these  conditions  being  well  calculated  to 
increase  the  local  nutrition.     Dieffenbach  went   one  step  farther,  and 


BONE.  55 

advised  the  use  of  ivory  nails,  which  were  allowed  to  remain  until  they 
became  loose  and  dropped  out.  The  term  non-union  is  a  relative  one,  as 
in  some  fractures  this  condition  ma}'  have  been  reached  in  three  to  four 
months,  while  others  may  unite  after  a  3-ear. 

In  a  fracture  of  the  femur  in  a  health}'  man,  who  came  under  the 
author's  observation,  that  had  not  united  a  year  after  the  accident,  bony 
consolidation  took  place  after  this  time  without  any  operative  inter- 
ference. In  another  case  bonj-  union  did  not  occur  until  nearly  two  3'ears 
after  the  fracture  had  taken  place.  When  a  pseudarthrosis  has  once 
become  established,  all  measures  which  have  been  found  useful  in  the 
treatment  of  delayed  union  are  useless,  and  the  onlj^  rational  treatment 
in  such  cases  consists  in  transforming  the  old  fracture  into  a  recent  one. 
Tlie  ends  of  the  fragments  are  exposed,  the  interposed  ligamentous 
structures — muscles  or  tendons — or  false  joint  excised,  and  the  ends 
vivified  in  such  a  manner  as  to  furnish  large  surfaces  for  apposition. 
The  bone  should  never  be  cut  transversely^  but  alwa^'s  obliquely,  or, 
what  is  still  better,  Volkmann's  step-operation  should  be  done  wherever 
the  existing  conditions  make  this  possible.  Direct  fixation  of  the  frag- 
ments with  aseptic  bone  or  ivory  nails  should  always  be  practiced,  as  by 
this  expedient  we  are  able  to  secure  greater  immobilit}^  between  the 
fragments,  and  at  the  same  time  the  perforations  and  the  presence  of  the 
foreign  bodies  cannot  fail  in  imparting  an  additional  stimulus  to  the 
tissues  which  will  expedite  the  process  of  repair. 

The  frequency  with  which  non-union  is  met  with  after  intra-capsular 
fracture  of  the  neck  of  the  femur  has  almost  b}'  universal  consent  been 
attributed  to  defective  callus  formation.  It  has  been  claimed  that  in 
such  a  fracture,  occurring  as  it  usually  does  in  persons  advanced  in  life, 
callus  production  is  always  defective,  and,  as  the  upper  fragment  is  but 
scantily  supplied  with  blood-vessels,  it  was  asserted  tliat  it  was  not  in  a 
condition  to  take  an  active  part  in  the  reparative  process.  The  author 
made  numerous  experiments  on  animals,  fracturing  the  neck  of  the  femur 
within  the  limits  of  the  capsular  ligament,  and  as  long  as  the  fracture 
was  treated  in  the  customary  way  bou}-  union  was  never  attained.  He 
then  resorted  to  direct  means  of  fixation  by  transfixing  both  fragments 
with  an  absorbable  nail,  and  with  this  treatment  succeeded  in  obtain- 
ing bon}'  union  in  the  majority  of  cases.  Since  that  time  he  has 
treated  fractures  of  the  neck  of  the  femur  by  immediate  reduction 
and  permanent  fixation  with  a  plaster-of-Paris  splint,  with  pressure 
over  the  trochanter  major  in  the  direction  of  the  axis  of  the  neck  of 
the  femur  with  a  compress  and  set-screw,  the  latter  passing  through 
a  splint  which  is  incorporated  in  the  plaster-of-Paris  dressing.  With 
this  treatment  he  has  obtained  bony  union  in  a  number  of  instances, 


56  PRINCIPLES   OF    SURGERY. 

where  all  the  signs    and    sjanptoms  pointed   to  a  fracture  within  the 
capsular  ligament. 

It  is  a  well-established  clinical  fact  that  in  the  aged  other  fractures 
unite  readily,  and  pseudarthrosis  is  exceedingly  uncommon,  excepting 
after  this  fracture;  and  the  writer  is  satisfied  that  this  undesirable  result 
occurs  more  in  consequence  of  improper  treatment  than  defective  callus 
production.  If  the  fragments  can  be  brought  in  accurate  apposition 
soon  after  the  accident  has  occurred,  and  coaptation  can  be  maintained 
uninterruptedly  for  three  months  b}'  an  appropriate  dressing,  l)on3'  union 
can  be  secured  not  only  in  exceptional,  but  in  the  majority  of,  cases. 
In  the  treatment  of  fractures,  as  in  the  treatment  of  wounds  of  the  soft 
parts,  accurate  coaptation  and  effective  fixation  should  be  aimed  at  so  as 
to  place  the  parts  in  the  most  favorable  conditions  to  unite  by  the 
smallest  possible  amount  of  new  material. 

GLANDS. 

Griffini  studied  regeneration  of  testicle-substance  in  frogs,  dogs, 
chickens,  and  guinea-pigs.  He  excised  a  wedge-shaped  piece  under  strict 
antiseptic  precautions,  and  killed  the  animals  in  from  three  to  seventy- 
five  days.  Examination  of  the  specimens  showed  that  an  increase  of 
tubuli  seminiferi  had  invariably  taken  place.  They  appeared  to  have 
originated  as  blind  pouches  from  pre-existing  tubules,  T-izzoni  has  also 
observed,  in  his  experiments  on  dogs,  production  of  new  gland-tissue 
during  the  healing  of  wounds  of  the  liver  and  after  partial  excision  of 
this  organ.  The  same  author  studied  experimentally  regeneration  of  the 
spleen-tissue,  and  found  that  this  occurred  after  partial  and  complete 
extirpation,  the  new  tissue  being  made  up  of  elements  in  connection  with 
blood-vessels  of  the  adjacent  peritoneum.  After  complete  extirpation 
of  the  organ  the  new  spleens  appear  as  nodules  of  a  brownish  color, 
which  are  attached  to  the  vessels  of  the  peritoneum,  and  develop  around 
new  buds  of  these  vessels.  The  beginning  of  such  a  minute  spleen 
appears  as  an  accumulation  of  new  loose  connective  tissue,  in  the  meshes 
of  which  13'niph-corpuscles  are  found  ;  later,  follicles  and  pulp-substance 
appear,  with  a  corresponding  arrangement  of  blood-vessels.  As  these 
little  organs  always  appear  about  the  hilus  of  the  spleen,  they  cannot  be 
supernumerary  spleens.  After  excision  of  wedge-shaped  pieces  of  the 
spleen,  formation  of  new  spleen-tissue  has  also  been  observed  upon  the 
omentum  at  a  point  opposite  the  wound  and  independently  from  tissue 
proliferation  in  the  wound.  Reproduction  of  tissue  therefore  takes  place 
in  the  same  manner  as  in  the  regeneration  of  lymphatic  tissue.  After 
the  removal  of  the  entire  spleen,  tissue  proliferation  takes  place  in  the 
adjacent  blood-vessels,  the  product  of  which  corresponds  with  normal 


CENTRAL    NERVOUS   SYSTEM.  57 

splenic  tissue,  and  doubtless  possesses  the  same  physiological  functions. 
As  the  immediate  result  of  such  proliferation  an  altered  condition  of  the 
vessels  must  be  accepted,  as  the  blood-vessels  of  the  omentum  and  peri- 
toneum correspond  with  the  fundus  of  the  stomach.  Mayer  claimed 
regenerative  capacity  for  the  pulp  of  the  spleen,  but  he  may  have  been 
deceived  b^^  the  presence  of  lymphatic  glands  of  the  color  of  the  spleen 
at  the  seat  of  extirpation.  Picard  and  Malassez,  Bizzozero  and  Salvioli, 
and  finally  Tizzoni  and  Fileti  showed  that  after  splenectomy  a  diminu- 
tion of  the  blood-corpuscles  is  observed  first,  but  as  the  new  spleen-tissue 
is  produced  their  number  again  increases.  Baier  and  Bacialli  have 
showMi,  b}- their  experimental  investigations,  that  new  l^'mphatic  tissue  is 
rapidly  produced  after  partial  as  well  as  after  complete  removal  of  a 
lymphatic  gland.  In  the  regeneration  of  this  tissue  the  adjacent  adipose 
tissue  appeared  to  take  an  active  part.  According  to  Baier,  the  adipose 
tissue  is  first  infiltrated  with  leucocytes,  while  Bacialli  saw  new  endo- 
thelial cells  and  lymph-spaces  develop  from  the  connective-tissue  cells, 
after  having  seen  mitotic  figures  in  the  nuclei.  After  complete  extirpa- 
tion of  a  lymphatic  gland,  reproduction  of  Ijanphoid  structure  in  all 
probability  does  not  take  place  from  any  other  but  lymphatic  tissue,  and 
the  new  gland-tissue  is  the  product  of  tissue  proliferation  from  the  cut 
ends  of  13'mphatic  vessels. 

CENTRAL  NERVOUS  SYSTEM. 
The  central  nervous  sj-stem  is  built  up  partly  from  the  mesoblast 
and  partly  from  the  epiblast.  The  stellate  and  spider-shaped  cells  are 
derived  from  the  mesoblast,  while  the  neuroglia  and  the  nerve-cells 
proper  spring  from  the  neuroblast,  a  part  of  the  epiblast,  which,  in  the 
embr3'o,  is  located  nearest  the  middle  axis.  The  neuroglia  represent 
channels  of  nutrition,  which  are  formed  only  at  a  time  when  the  neuro- 
blastic  tissues  have  reached  the  height  of  their  development.  The 
mesoblastic  portion  of  the  brain  and  spinal  cord  does  not  increase  dur- 
ing the  healing  of  a  wound  of  these  parts.  In  pathological  conditions, 
however,  as  in  cases  of  multiple  sclerosis,  the  stellate  and  spider-shaped 
elements  proliferate  so  active!}'  that  the  nerve-cells  are  completely  dis- 
placed b}'  the  new  product.  Man}^  authors  have  expressed  their  doubts 
as  to  the  possibilit}'  of  regeneration  of  brain-tissue  after  injury  or  dis- 
ease, while  others  have  gone  to  the  opposite  extreme,  and  claim  that 
complete  I'epair  can  take  place  in  cases  of  extensive  defects.  Yoit  claims 
that  in  pigeons  he  has  observed  complete  restoration  of  both  structure 
and  function  after  extirpation  of  the  entire  cerebrum.  While  large  de- 
fects are  not  repaired,  the  regenerative  capacity  of  the  nervous  elements 
cannot  be  doubted,  and    such  a  doubt  would  come  in  conflict  with  a 


58  PRINCIPLES   OF    SURGERY. 

general  law.  Regeneration  of  the  cerebral  nervous  sj'stem  comprises  the 
production  of  new  ganglia-cells  and  neuroglia,  the  latter  consisting  of  a 
fine  net-work,  sometimes  of  nervous,  at  others  of  basis,  substance. 
During  the  healing  of  every  wound  of  the  brain  the  observer  can  satisfy 
himself  that  the  neuroglia  possesses  a  high  capacit}'  of  reproduction,  as 
well-marked  karyokinetic  changes  can  be  seen  during  the  first  twenty- 
four  hours  after  the  injury.  The  new  cells  are  very  abundant,  and  arrange 
themselves  in  groups.  More  difficult  is  the  demonstration  of  the  same 
changes  in  the  ganglia-cells,  but  Mondino  (1886)  and  Coen  (1887)  have 
given  descriptions  of  these  cells  which  leave  no  further  doubt  that  they 
also  multiply  l\y  karyokinesis.  Klebs  has  also  observed  karyokinetic 
figures  in  the  nuclei  of  ganglia-cells  during  the  repair  of  injuries  of  the 
brain.  In  the  embryo,  increase  of  ganglia-cells  by  karyokinesis  has  been 
witnessed  by  Pfitzner,  Uskoff,  Rauber,  Merk,  and  Cattani.  It  is  true 
that  brain  wounds  heal  with  some  defects,  but  this  applies  to  extensive 
injuries  in  which  the  regenerative  capacit}'^  of  the  brain-substance  is  not 
equal  to  the  emergency ;  hence,  only  a  part  of  the  defect  is  repaired. 
Klebs  gives  an  accurate  account  of  his  examination  on  the  reparative 
process  in  two  cases  of  brain  injurj^ — one  recent,  the  other  of  long  stand- 
ing. Microscopical  examination  of  the  tissues  from  the  seat  of  injury 
in  both  cases  showed  that  new  tissue  had  been  produced.  He  found  many 
new  cells  from  the  neuroglia  which  he  is  inclined  to  believe  may  func- 
tionally take  the  place  of  ganglia-cells.  The  same  author  made  numerous 
experiments  on  young  animals  for  the  purpose  of  studying  the  process 
of  healing  in  wounds  of  the  brain.  With  an  aseptic  needle  the  brain 
was  punctured.  No  s^'mptoms  followed  the  injur}'.  The  brain  was 
examined  from  two  to  four  days  after  puncture  ;  only  slight  meningeal 
hoemorrhage.  The  needle-track  in  the  brain  not  closed.  Mitotic  changes 
were  found  not  in  the  cells  in  the  immediate  neighborhood  of  the  punc- 
ture, but  in  the  cells  corresponding  to  from  the  second  to  the  fifth  row 
from  it.  In  the  same  place  were  found  an  accumulation  of  resting  nuclej. 
Mitotic  cell  proliferation  of  injured  cells  was  found  completed  on  the 
fourth  day.  Ganglia-cells  undoubtedl}'  increase  in  number  in  the  same 
manner.  He  found  no  leucocvtes  in  the  brain,  and  believes  that  those 
that  must  have  been  present  had  been  appropriated  as  food  bj'  the  cells 
which  had  undergone  karyokinetic  changes.  The  gray  matter  of  the 
surface  of  the  brain  is  composed  of  numerous  but  exceedingly  small 
cells,  and  their  numerous  connections  would  indicate  great  reproductive 
capacitv. 

Peripheral  Nerves. — When  Cruikshank  suggested  the  possibility  of 
restoring  physiological  function  in  a  divided  nerve  by  suturing,  his  con- 
temporaries regarded  the  suggestion  as  an  absurdity.     Since  that  time 


CENTRAL   NERVOUS   SYSTEM.  59 

the  subject  of  nerve  regeneration  has  engaged  the  attention  of  some  of 
the  best  men  in  the  profession,  and  from  the  knowledge  which  has  thus 
accumulated  it  is  safe  to  repeat  the  statement  made  b}^  Vanlair  recently, 
that  "  the  surgeon  who  neglects  to  suture  a  divided  nerve  commits  the 
same  mistake  as  he  who  neglects  to  reduce  a  fracture  or  fails  to  unite  a 
divided  tendon."  Regeneration  of  a  nerve  takes  place  exclusively  from 
pre-existing  nerve-fibres.  Schwann's  sheath  isolates  the  nerve-fibre  so 
thoroughl}'  from  the  mesoblast  that  it  would  be  almost  impossible  for 
the  latter  to  take  an}-  direct  or  active  part  in  the  regeneration  of  the 
former.  The  neuroblasts  from  which  tissue  proliferation  takes  place 
are  found  within  the  nerve-sheath.  Confluenceof  the  new  nerve-elements 
within  the  neurolemma  does  not  take  place,  as,  according  to  Cattani, 
they  receive  envelopes  from  the  medulla.  Section  of  a  motor  fibre  is  at 
once  followed  by  degeneration  of  the  motor  terminal  palate  ;  hence,  degen- 
eration and  regeneration  in  the  divided  nerve  and  the  muscles  supplied 
b}'  it  are  parallel  processes.  Degeneration  and  regeneration  have  been 
studied  in  nerves  that  were  stretched,  lacerated,  or  completel}'  cut  across, 
and  the  histological  processes  were  found  almost  identical  in  all  of  these 
conditions.  The  stud}'  of  degenerative  and  regenerative  processes  side 
by  side  in  injured  nerves  has  thrown  much  light  upon  their  minute 
anatomj'.  The  medullated  peripheral  nerve-fibre  is  composed  essentially 
of  Schwann's  sheath,  the  axis-cylinder,  and  a  fluid  which  appears  as  a 
periaxial  la3-er.  Klebs  looks  upon  this  fluid  as  a  sort  of  nervous  endo- 
lymph,  which,  b}'  virtue  of  its  great  mobility',  takes  part  in  the  nutrition 
of  the  nerve.  The  space  which  contains  the  fluid,  being  between  the 
axis-C3'linder  and  the  sheath,  serves  not  only  the  purpose  of  a  channel 
for  the  fluid,  but  also  for  the  dissemination  of  movable  elements,  as,  for 
instance,  migration  corpuscles.  Leucoc3^tes  are  only  present  in  any 
considerable  number  in  pathological  conditions.  Schwann's  sheath  is 
composed  of  connective  tissue.  The  large  oval  nuclei,  containing  each 
one  or  two  shining  nucleoli,  which  are  attached  to  its  inner  side,  are  the 
neuroblasts.  It  is  as  yet  not  definitely  settled  whether  the  portion  of 
nerve  between  two  of  Ranvier's  constrictions  is  composed  of  one  or 
more  cells.  Klebs  is  inclined  to  accept  the  view  that  such  a  space  is 
represented  b}-  one  cell,  and  if  several  nuclei  are  present  the}'^  are  the 
product  of  nuclear  segmentation.  The  nuclei  must  be  regarded  in  the 
light  of  peripheral  nerve-cells.  The  specific  functional  contents  of  a 
nerve-fibre  are  the  axis-c3-linder,  the  endolymph,  and  medulla.  The  first 
two  are  continuous  with  the  neighboring  elements,  but  not  so  the  medul- 
lar}- sheath.  The  medullary  sheath  is  a  ver}'"  complicated  structure. 
The  masses  of  fat  are. held  together,  and  are  inclosed  by  a  frame-work  of 
keratin.     Finer  keniiin  threads  unite  both  sheaths  in  the  form  of  Golgi's 


60  PRINCIPLES   OF   SURGERY. 

spirals,  which  are  present  in  the  funnels  of  Schmidt-Lautermann's  med- 
ullar}^ spaces ;  besides,  numerous  transverse  threads  are  strung  out  in 
zigzag  shape  between  the  sheaths.  The  constituent  parts  of  the  medul- 
lary portion  of  the  nerve-fibre  can  disappear  separately  ;  if  the  medullary 
fat  is  removed  by  absorption,  the  keratin  frame-work  becomes  visible, — a 
condition  which  is  present  during  the  early  stages  of  neuritis  parenchy- 
matosa  ;  if  the  keratin  frame-work  is  dissolved,  the  fat  appeal's  in  drops, 
as  can  be  seen  during  the  degeneration  of  a  nerve  after  section.  The 
axis-cylinder  is  a  pre-existing  structure,  which,  however,  can  be  only 
distinctly  outlined  against  the  medullary  sheath  and  endolymph  by 
post-mortem  influences.  Its  structure,  in  the  larger  medullated  fibres  at 
least,  is  not  simple,  but  is  composed  of  fine  fibrillae,  held  together  b}^  an 
amorphous,  gelatinous  substance.  Physiologically,  this  part  of  the  nerve 
must  be  regarded  as  a  complex  of  different  conductors,  which  only  differ 
by  the  qualities  of  motility  and  sensibility.  Regeneration  of  a  periph- 
eral nerve-fibre  is  a  regular  typical  process,  as  far  as  it  serves  as  a 
substitute  for  lost  elements  of  a  nerve.  The  process  resembles  the 
physiological  growth  of  a  nerve  which  always  occurs  only  in  connection 
with  the  centi'al  nervous  system.  If  the  separation  between  the  nerve- 
ends  exceeds  an  inch,  restoration  of  its  continuity  without  assistance 
cannot  take  place.  In  such  an  event  the  ends  become  bulbous,  the 
medullary  substance  in  the  distal  portion  undergoes  degeneration,  and 
the  axis-cylinder  becomes  more  and  more  indistinct.  The  same  changes 
take  place  in  the  nerve-ends  after  amputation.  When  a  nerve  is  simply 
divided,  and  there  is  no  loss  of  substance,  the  ends  remaining  in  close 
contact,  function  is  established  in  a  remarkably  short  time.  In  two 
instances  Gluck  observed  perfect  function  within  twenty-four  hours.  He 
concludes  that  the  granulation  tissne  must  have  been  the  means  of  con- 
duction in  these  cases.  In  his  experiments  on  the  sciatic  nerve  in  fowls, 
where  he  divided  the  nerve  and  immediately  sutured  with  catgut,  func- 
tion was  restored  in  from  fifty  to  eighty-six  hours.  Waller  and  Vanlair 
are  of  the  opinion  that  regeneration  proceeds  entirel}^  from  the  proximal 
end.  Colasanti  claims  that  degeneration  of  the  peripheral  end  only 
extends  as  far  as  the  next  Ranvier's  ring,  while  Tizzoni  found  that 
degeneration  extends  from  the  seat  of  injury  in  both  directions,  only 
that  it  is  more  marked  on  the  distal  side.  Most  of  the  recent  writers  on 
the  subject  assert  that  when  a  piece  of  the  nerve  is  resected  the  entire 
nerve  on  the  distal  side  undergoes  degeneration,  while,  if  the  nerve  is 
only  divided,  and  the  ends  are  immediately  sutured,  at  least  a  number 
of  the  nerve-fibres  retain  their  integrity.  Eichhorst  and  others,  who 
have  made  regeneration  of  the  nerves  a  special  study,  are  of  the  opinion 
that  the  nerve-fibres  of  both  ends  participate  in  the  process  of  repair, 


CENTRAL   NERVOUS   SYSTEM. 


61 


and  that  regeneration  commences  with  degeneration.  Eichhorst  believes 
that  regeneration  takes  place  exclusively  by  splitting  of  the  axis-c}  linder 
within  Schwann's  sheath,  so  that  the  latter  in  the  course  of  time  becomes 
distended  with  them.  Continuity  is  restored  by  the  central  fibrils  l^eing 
pushed  outward  through  the  cicatrix  to  meet  the  peripheral,  and  coales- 
cence follows.  Beueke,  on  the  other  hand,  traced  the  origin  of  the  new 
fibres  to  protoplasm  of  the  neuroblasts,  which  are  transformed  into 
delicate  fibrils,  which  become  surrounded  b}-  a 
coating  of  myeline,the  future  medulla.  It  is  more 
probable  that  regeneration  of  a  nerve  takes  place 
by  the  latter  method.  After  a  trauma,  reproduc- 
tion of  the  axis-c3^1inder  alwa^'s  follows.  Accord- 
ing to  a  number  of  investigators  who  have  studied 
this  subject,  several  axis-cylinders  are  formed 
within  each  Schwann's  sheath,  each  of  which  is 
surrounded  by  a  separate  medullary  sheath.  It 
is  difficult  to  ascertain  whether  these  new  fibres, 
growing  out  of  one  of  the  old  fibres,  again  become 
united  some  distance  toward  the  periphery,  or 
whether  they  remain  isolated  to  their  point  of 
peripheral  distribution.  After  nerve  section,  the 
axis-cylinder  swells  at  the  cut  end  and  becomes 
striated ;  this  swelling,  however,  is  not  an  active 
process,  but  the  result  of  imbibition  of  stagnant 
endolymph.  The  longitudinal  striations  and  for- 
mation of  vacuoles  which  have  been  described 
by  Tizzoni  are  due  to  the  same  cause.  The  gran- 
ular appearance  is  brought  about  by  disintegra- 
tion of  the  fibrillae.  The  old  axis-cj'^linder  breaks 
down  into  isolated  fragments,  which,  in  part  at 
least,  are  removed  b}^  leucocytes,  which  at  this 
time   have  made  their   appearance.      With  such 


Fig.  27.— Nerve-fibre  in 
A  State  op  Regenera- 
tion Fifty  to  Seventy 
Hours  after  Injury. 
{Gluck.) 

A,    proliferation  of  neuroblasts ; 

B,  spindle-cell,  which,  becoming 
conflvient  with  similar  cells  from 
both  sides,  unites  the  nerve-fibres  ; 

C,  rows  of  spindle-cells,  forming 
amyelinic  nerve-fibres:    D,    young 

extensive  destructive  changes  in  the  axis-cvlinder   aniyeioid  ceiis,  formed  from  nuclei 

~  "of  neurolemma. 

it  is   difficult   to  conceive   how  regeneration   of 

this  structure  could  take  place  in  the  manner  described  b}'  Eichhorst. 
The  only  histological  elements  within  the  fibre-sheath  exempt  from 
degeneration  are  the  nuclei  of  the  inner  surface  of  the  sheath,  the  neuro- 
blasts, and  from  these  regeneration  takes  place. 

At  the  seat  of  regeneration  the  nerve  is  enlarged  from  the  accumu- 
lation of  the  products  of  tissue  proliferation  within  the  neurolemma 
sheaths. 

The  first  stage  of  regeneration  of  a  nerve  is  initiated  by  multiplica- 


62 


PRINCIPLES   OF    SURGERY. 


tion  of  the  neuroblasts  and  increase  of  protoplasm.  The  nuclei  increase 
to  double  their  normal  size  and  then  divide  into  two  or  more.  Division 
of  nuclei  probably  takes  place  b}'  karyokinesis.  The  protoplasm  is  gran- 
ular, and  is  stained  a  reddish  color  with  neutral  picrocarmine.  The 
nerve-fibre  originates  from  the  protoplasm,  and,  according  to  Tizzoni,  in 
the  form  of  separate  pieces,  around  which  already  can  be  distinguished  a 
medullar}'  sheath  and  transparent  contents.  In  other  cases  there  may  be 
a  direct  connection  between  the  old  and  new  axis-cylinder.  Longitudi- 
nal striation  of  the  axis-cylinder  prob- 
ably takes  place  at  a  time  when  the  fibre 
has  formed  a  direct  connection  with  dis- 
tant parts,  the  seat  of  active  physiologi- 
cal processes.  Leucocytes  have  been  found 
within  the  neurolemma  by  Tizzoni  and 
Korybut-Daskiewicz,  while  Neumann  de- 
nies their  presence  in  this  locality.  Cattani 
believes  that  they  are  present  within  the 
fibre-sheath  after  nerve-stretching,  and  can 
be  found  as  far  as  the  motor  ganglia  of  the 
cord.  Nerves  of  difterent  function,  when 
united,  will  undergo  repair  and  establish 
useful  conductors  for  the  transmission  of 
nerve  force.  The  late  Professor  Gunn  estab- 
lished the  correctness  of  this  assertion  by 
a  series  of  interesting  experiments  on  dogs. 
Early  functional  results  after  nerve  suture 
are  often  fallacious,  as  the  function  at- 
tributed to  sutured  nerves  may  be  per- 
formed by  other  nerves  which  reach  over 
such  areas  ;  and,  again,  the  peripheral  mani- 
festation may  be  the  result  of  physical  con- 
duction of  the  irritation,  and  apparent 
motor  recoveries  may  be  stimulated  by  the  action  of  muscles  other  than 
those  supplied  by  the  sutured  nerve. 


Fig.  28.— Lu.n(;itu]jixal  Section 
THROUGH  Nerve  Twenty-one 
Days  after  Injury,  show- 
ing Meduli.,ated   and   Non- 

MEDULLATED       NeRVE-FIBRES 

with  Round  Cells  between 

THEM.      (Gluck.) 


NERVE  SUTURE. 

Nerve  suture  was  first  performed  by  Baudens  in  1836,  with  negative 
result.  The  procedure  was  revived  b)^  Nelaton  in  1863,  and  the  follow- 
ing 3'ear  by  Langier.  The  first  operations  were  made  with  fine  silk 
sutures,  which  were  not  cut  short,  and  subsequently  came  away  by  suppura- 
tion. O.  Weber  advised  to  unite  the  nerve-ends  by  passing  the  sutures, 
not  through  the  nerve-substance,  but  only  through  the  connective  tissue 


NERVE  SUTURE. 


63 


DireetSutaro 


Pe/TntwumZ 
Suiure 


surrounding  the  nerve, — the  paraneurotic  suture.  Experience,  however, 
has  shown  that  transfixion  of  the  nerve-ends  by  the  sutures  does  not 
give  rise  to  pain,  and  does  not  interfere  with  the  normal  reparative 
processes,  and  at  the  same  time,  by  resorting  to  this  direct  method  of 
suturing,  more  perfect  coaptation  is  secured.  In  the  case  of  large  nerves, 
it  is  advisable  to  re-inforce  the  direct  sutures  with  a  number  of  para- 
neurotic sutures.  The  best  material  for  the  sutures  is  aseptic  catgut. 
An  ordinary  sewing-needle  with  a  dull  point  is  preferable  to  a  surgical 
needle,  as  it  is  more  sure  to  pass  through  the  nerve  without  injuring  the 
fibres. 

From  one  to  three  direct  sutures,  according  to  the  size  of  the  nerve, 
are  applied,  and  from  three  to  six  paraneurotic  sutures.  The  needle  is 
passed  straight  through  the  nerve  on  each  side,  one-eighth  to  one-fourth 
of  an  inch  from  the  ends,  and  care  must  be  exercised,  in  tying  the  sutures, 
to  bring  the  cut  surfaces  in  accurate  apposition, 
and  not  to  tie  the  sutures  too  tightly,  as  by  doing 
so  the  nerve-ends  are  liable  to  become  displaced 
by  overlapping.  In  t3nng  the  paraneurotic  sutures 
the  necessary  precautions  must  be  taken  to  pre- 
vent tlie  margins  of  the  sheath  from  insinuating 
themselves  between  the  nerve-ends. 

Primary  Nerve  Suture. — A  primary  nerve 
suture  is  one  used  to  unite  a  nerve  immediately 
or  soon  after  the  injury  has  occurred,  and  before 
any  degenerative  changes  have  taken  place.  It 
should  always  be  resorted  to  in  the  treatment  of 
accidental  wounds  where  one  or  more  nerves  have 
been  divided,  also  where  in  operations  a  nerve 

has  been  divided  accidentally,  and,  finally,  in  cases  where  a  neurectomy 
for  pathological  conditions  cannot  be  avoided.  The  results  after  primary 
suture  have  been  very  satisfactory.  Bruns  has  collected  71  cases  from 
different  sources,  and  in  more  than  33  per  cent,  of  the  number  function 
was  restored.  As  suppuration  in  a  wound  where  a  nerve  has  been 
sutured  would,  in  all  probability,  cause  tearing  out  of  the  sutures  and 
displacement  of  the  nerve-ends,  it  is  of  the  greatest  practical  importance 
to  secure  for  such  wounds  an  aseptic  condition  and  to  obtain  primary 
union  throughout,  and  consequently  no  provision  for  drainage  should 
be  made.  If  the  wound-surfaces  cannot  be  approximated,  and  a  greater 
or  less  space  has  to  fill  up  by  granulation,  a  bundle  of  catgut  threads 
can  be  used  for  a  capillar^'  drain,  in  order  to  avoid  tension  from  the  accu- 
mulation of  blood  or  the  primary  wound-secretion. 

Secondary  Nerve  Suture. — When  a  divided  nerve  fails  to  unite,  the 


Viij.  29.— Nerve  Suture, 
SHOWING  Applica- 
tion OF  Direct  and 
Pakaneurotic  Su- 
tures. 


64  PRINCIPLES   OF    SURGERY. 

ends  become  bulbous,  are  usually-  found  imbedded  in  a  mass  of  cica- 
tricial tissue,  and  sei)arated  from  each  otlier  from  1  to  2  or  more  inches. 
Function  below  the  point  of  division  is  completely  lost;  the  distal  por- 
tion of  the  uerve  itself,  being  no  longer  in  connection  with  the  central 
nervous  system,  undergoes  degeneration,  and  the  muscles  supplied  by  the 
injured  nerve  become  atrophic  and  useless.  The  reuniting  of  such  a 
nerve  is  done  b}^  the  secondary  suture.  Experience  has  shown  that 
function  can  be  restored  by  this  procedure  years  after  the  injury. 
Jessop  vivified  the  nerve-ends  and  applied  sutures  nine  years  after  iii- 
jur^^  of  the  median  nerve,  and  restored  function.  Langenbeck  sutured 
the  sciatic  nerve  two  years  after  division  ;  sensation  returned  in  three 
days,  and,  later,  motion.  As  a  rule,  sensibility  returns  first  after  nerve 
suture,  followed  considerably  later  by  restoration  of  motor  function. 
The  most  speedy  restoration  of  function,  both  sensory-  and  motor,  after 
secondary  suture  is  reported  by  Tillaux.  He  operated  on  the  median 
nerve  three  years  after  division.  The  ends  were  found  imbedded  in  a 
cicatrix  and  separated  from  each  otiier  4  centimetres.  The  ends  were 
vivified  and  sutured.  He  claimed  that  physiological  function  was  re- 
stored completely  three  hours  after  the  operation.  There  can  be  no 
doubt  of  the  ultimate  recovery  of  nerve  function  in  this  case,  but  that 
this  should  have  been  attained  in  three  hours  appears  next  to  impossible. 
Enough  has  been  said  to  show  that  secondary  nerve  sntui'e  can  be  re- 
sorted to  with  good  prospects  of  success  years  after  an  injury,  but  for 
well-known  reasons  it  should  not  be  postponed  after  it  has  become  evi- 
dent that  union  has  failed  to  take  place.  Unnecessary  delay  is  danger- 
ous, because  when  a  nerve  has  become  permanently  disconnected  from 
the  central  nervous  system  muscular  degeneration  goes  hand  in  hand 
with  degeneration  of  the  distal  portion  of  the  nerve,  and  the  longer  the 
operation  is  delayed  the  greater  the  length  of  time  required  to  complete 
the  regeneration  of  the  nerve  and  the  muscles.  The  first  secondary 
nerve  suture  was  made  by  Nelaton  in  1865.  In  Grermau}',  the  first  opera- 
tion was  made  by  Guster  Simon  in  1876,  and  he  was  followed  b}^  Lan- 
genbeck the  following  year.  In  1884,  Bruns  found  33  recorded  cases, 
and  in  24  of  this  number  the  result  was  satisfactory.  Asa  rnle,  sensa- 
tion returned  gradually  in  from  two  to  four  weeks,  while  motion  did  not 
return  until  three  weeks  to  three  months  after  the  operation.  Complete 
restoration  of  function  was  seldom  completed  until  half  a  j-ear  to  one  year 
after  the  operation.  As  in  oases  which  require  secondary  suture  the  nerve- 
ends  are  sealed  with  a  mass  of  cicatricial  tissue,  it  is  always  necessary  to 
resect  the  ends,  after  which  the  sutures  ai-e  applied  in  the  same  manner 
as  in  primary  nerve  suture.  Both  nerve-ends  must  be  freed  from  all 
cicatricial   adhesions   before   approximation    is  attempted,  and.  if  this 


NERVE    SUTURE.  65 

cannot  be  readily  clone  on  account  of  previous  retraction,  both  ends  are 
carefully  stretched  and  sufficient  elongation  secured  so  as  to  prevent  any 
tension  upon  the  sutures.  A  great  deal  can  be  done  to  prevent  tension, 
by  placing  the  limb  in  such  a  position  as  will  relax  the  nerve  ;  for  in- 
stance, flexion  of  the  hand  and  forearm  in  suturing  the  ulnar,  median,  or 
musculo-spiral,  and  flexion  of  the  leg  and  extension  of  thigh  after  re- 
uniting the  sciatic.  The  position  of  the  limb  most  favorable  for  the 
union  of  a  sutured  nerve  is  best  secured  by  a  plaster-of-Paris  dressing, 
which  is  allowed  to  remain  not  only  till  the  external  wound  is  healed,  but 
until  the  nerve  has  firmly  united.  When  a  nerve  has  suffered  at  the  seat 
of  injur}'  a  considerable  loss  of  substance,  it  is  often  found  impossible  to 
bring  their  ends  in  contact  by  nerve-stretching  and  position  of  limb,  and  in 
such  cases  restoration  of  continuity  becomes  an  exceedingly^  difficult  task. 
Letievant  suggested  that  the  defect  in  such  cases  should  be  cor- 
rected b}'  a  neuroplastic  operation.  He  proposed  that  a  flap  should  be 
taken  from  each  end  sufficiently  long  that,  when  turned  toward  each 
other,  they  could  be  sutured  at  the  middle  of  the  defect,  thus  making  a 
connecting  bridge  of  nerve-tissue  between  the  separated  nerves.  As 
could  be  expected,  in  a  case  where  he  performed  this  operation  the  result 
was  negative.  In  a  case  operated  on  by  Tillmanns  after  this  method, 
partial  restoration  of  function  was  established  three  and  a  half  months 
after  the  operation.  The  success  in  this  case  was  probably  not  the  result 
of  conduction  of  nerve  force  along  the  fibres  of  the  flaps,  but  the  pro- 
duction of  new  fibres  across  the  gap,  perhaps  through  the  tissues  com- 
posing the  temporar}'^  bridge.  From  his  experiments  on  animals,  Gluck 
came  to  the  conclusion  that  nerve  defects  could  be  corrected  by  trans- 
plantation of  nerves  ;  that  is,  inserting  a  piece  of  nerve  from  an  animal, 
corresponding  in  size  to  the  nerve  to  be  reunited,  between  the  nerve  ends, 
and  uniting  it  with  them  with  sutures.  He  reports  a  number  of  success- 
ful experiments  on  chickens,  filling  the  gap  with  a  nerve  taken  from 
rabbits.  Philipeaux  and  Vulpian,  from  their  own  researches,  came  to 
the  conclusion  that  a  transplanted  nerve  alwaj's  degenerates  and  dis- 
appears, and  that  restoration  of  structure  and  function  only  takes  place 
by  regeneration  from  the  nerve-ends.  It  is  probable  that  the  methods 
of  nerve  restoration  devised  by  Letievant  and  Gluck  are  useful  in  reunit- 
ing separated  nerve-ends  in  the  same  manner  as  the  suture  a  distance  of 
catgut  suggested  by  Assakv.  The  interposition  of  an  aseptic,  absorbable 
substance  like  catgut  or  nerve-tissue  serves  as  a  temporary  scaffolding 
for  the  products  of  tissue  proliferation  from  the  nerve-ends,  which  at  the 
same  time  determines  the  direction  for  the  new  material,  providing  the 
shortest  route  to  meet  the  same  material  from  tlie  other  side.  When 
catgut  is  employed,  two  or  three  sutures  are  used,  so  that  the  combined 

5 


66  PRINCIPLES   OF   SURGERY. 

size  of  the  strings  will  at  least  approximately  correspond  to  the  size  of 
the  nerve.  VanUiir,  who  believes  that  regeneration  of  a  nerve  takes 
place  exclusively  from  the  proximal  end,  resected  a  piece  of  the  sciatic 
nerve  in  dogs,  and  then  sutured  both  ends  of  the  nerve  to  the  ends  of  a 
decalcified-bone  tube,  which  in  length  corresponded  to  the  section  of 
nerve  removed.  From  the  results  of  his  experiments,  10  in  number,  he 
became  satisfied  that  continuity  of  the  nerve  was  restored  by  the  new 
nerve-fibres  from  the  proximal  end  growing  into  the  tunnel,  bridging  the 
defect  in  a  comparatively  short  time,  as  they  had  no  resistance  to  over- 
come, and  uniting  with  the  end  of  the  nerve  on  the  opposite  side  of  the  tube. 
It  appears  to  the  author  that  this  metliod  of  overcoming  the  difficulties 
of  reuniting  nerve-ends  widely  apart  is  not  only  an  ingenious  procedure, 
but,  if  applied  in  practice,  promises  better  results  than  any  other  method 
heretofore  proposed.  In  certain  cases  where  the  distal  end  cannot  be 
found,  or  where  the  separation  is  so  great  that  none  of  the  methods  of 
approximation  so  far  devised  hold  out  any  inducements  of  a  successful 
issue,  Letievant  suggested  the  idea  of  grafting  the  central  end  upon  the 
intact  trunk  of  a  neighboring  nerve.  This  operation  failed  in  his  hands, 
but  Tillaux  and  Tillmanns,  slightly  modifying  the  method,  were  suc- 
cessful. In  Tillmanns'  case  the  ulnar  nerve  had  been  divided,  the  ends 
were  found  separated  4^  centimetres,  and  the  proximal  end  was  grafted 
upon  the  median  nerve.  Sensation  returned  in  a  month,  and  by  using 
electricity  and  massage  recovery  was  complete  a  year  later.  Nerve- 
grafting,  as  advocated  by  Letievant,  should  only  be  resorted  to  after 
implantation  of  a  decalcified-bone  tube  between  the  nerve-ends  has  been 
tried  and  proved  a  failure,  or  in  cases  where  the  defect  is  very  extensive, 
or,  finally,  if,  after  the  most  diligent  search,  the  distal  end  cannot  be 
found.  Restoration  of  function  does  not  always  follow  after  the  con- 
tinuity of  a  nerve  has  been  restored  by  operative  measures.  Ehrmann 
has  reported  such  a  case.  The  radial  nerve  was  divided  below  the  elbow 
and  failed  to  unite.  Complete  paralysis  of  all  the  muscles  supplied  by 
this  nerve.  After  the  lapse  of  .seven  months  the  nerve  was  exposed,  and 
the  ends,  which  were  5  centimetres  apart,  were  vivified  and  sutured. 
Seven  months  after  the  operation,  no  improvement.  The  nerve  was 
again  exposed  at  the  former  site  of  operation,  and  it  was  found  that  union 
had  taken  place,  but  the  nerve  was  compressed  by  a  firm  cicatrix  2  or 
3  centimetres  in  length.  The  nerve  was  relieved  from  its  imprisonment, 
and  when  the  faradic  current  was  applied  all  the  muscles  supplied  by  the 
nerve  responded.  Four  months  later,  complete  recovery.  This  case 
reminds  us  of  the  importance  of  securing  healing  of  the  nerve  and 
wound  with  as  little  cicatricial  tissue  as  possible,  which  can  onh^  be  done 
by  absolute  asepsis  and  careful  attention  to  suturing  of  the  wound. 


CHAPTER  III. 

Inflammation. 

The  subject  of  inflamuiation  is  one  of  deep  interest  both  to  the  stu- 
dent and  practitioner,  as  it  initiates  the  former  into  tlie  field  of  general 
and  special  pathology,  and  the  latter  meets  with  it  dail}-  in  some  form  in 
his  practice.  We  have  already  set  apart  from  inflammation  those  numer- 
ous processes  by  which  injuries  or  defects  are  repaired  without  destruc- 
tion of  an}^  of  the  new  tissue-elements  which  have  been  described  in  the 
first  chapter  under  the  head  of  Regeneration.  From  a  scientific  and 
practical  stand-point,  it  is  exceedingly  important  to  draw  a  distinct  line 
between  the  series  of  tissue  changes  which  attend  regenerative  processes, 
uncomplicated  by  the  action  of  pathogenic  bacteria,  and  true  inflamma- 
tion, which  is  always  caused  by  the  presence  of  one  or'  more  kinds  of  patho- 
genic microbes.  As  compared  with  true  inflammation  it  has  been  custom- 
ary for  quite  a  number  of  years  to  speak  of  regeneration  as  a  plastic  or 
regenerative,  inflammatory  process  ;  but  the  term  inflammation  in  the 
future  should  be  limited  to  the  series  of  histologiccl  changes  which  ensue 
in  the  living  body  from  the  presence  and  action  of  specific  micro-organ- 
isms, while  the  word  regeneration  should  be  used  to  designate  the  histo- 
logical changes  which  take  place  in  tissues  which  have  been  primaril}^  in 
an  aseptic  condition  or  have  been  rendered  so  after  the  inflammation  has 
subsided.  From  this  it  will  be  seen  that  the  study  of  inflammation  is 
intimately  and  inseparably  associated  with  a  consideration  of  the  new 
science  of  bacteriology.  For  most  forms  of  inflammation  the  presence 
of  a  specific  micro-organism  has  been  demonstrated,  and  its  etiological 
relationship  established  by  cultivation  and  inoculation  experiments;  and 
in  the  few  inflammatory  diseases  where  no  such  positive  proofs  can  be 
furnished  we  have,  from  analogy  and  circumstantial  evidence,  reason  to 
suspect  the  presence  of  undiscovered  microbes.  Inflammation,  in  the 
widest  and  most  comprehensive  meaning  of  the  word,  should  be  made  to 
embrace  pathological  conditions  which  are  caused  by  the  action  of  patho- 
genic microbes  or  their  ptomaines  upon  the  histological  elements  of  the 
blood  and  the  fixed  tissue-cells.  A  correct  definition  of  inflammation, 
which  should  embody  the  etiological,  anatomical,  and  pathological  char- 
acteristics of  the  disease  from  our  present  knowledge  of  the  subject, 
cannot  be  given,  as  many  important  points  connected  with  the  compli- 

(67) 


68  PRINCIPLES   OF   SURGERY. 

cated  processes  await  explanation  by  future  investigation.  Sanderson 
defines  inflammation  as  "  the  succession  of  changes  which  occur  in  a  living 
tissue  when  it  is  injured,  provided  that  the  injury  is  not  of  such  a  degree 
as  at  once  to  destroy  its  structure  and  vitality.''^  As  we  have  restricted 
the  term  inflammation  to  the  succession  of  changes  ivhich  occurs  in  a  liv- 
ing tissue  from  the  action  of  pathogenic  microbes  or  their  ptomaines, 
this  definition  would  cover  processes  which,  for  reasons  already  given, 
we  have  considered  as  instances  of  tissue  proliferation  unattended  by 
any  of  the  characteristic  features  of  inflammation.  J.  Bland  Sutton  uses 
the  term  inflammation  in  a  more  restricted  sense  in  coining  the  following 
definition  :  "  It  is  the  method  by  ivhich  an  organism  attempts  to  render 
inert  noxious  elements  introduced  from  ivithout  or  arising  luithin  it^  As 
nothing  is  said  of  the  method,  the  most  important  part  of  the  definition, 
it  certainl}^  cannot  be  said  to  cover  the  whole  ground.  The  conception 
of  the  true  nature  of  inflammation  for  the  present,  at  least,  must  remain 
symptomatic.  Asa  rule,  inflammation  subsides  as  soon  as  the  primary 
cause  has  disappeared  or  has  been  rendered  inactive,  as  is  well  shown  hy 
the  spontaneous  disappearance  of  febrile  disturbances  in  the  general  in- 
fective diseases,  and  the  subsequent  rapid  repair  of  the  local  lesions 
which  characterize  them.  If  an  acute  inflammation  become  chronic, 
either  from  a  diminution  of  the  quantitative  or  qualitative  intensity  of 
the  primary  cause,  or  from  the  tissues  becoming  accustomed  to  its  action, 
it  is  sometimes  difficult  to  tell  whether  the  primary  cause  has  disappeared 
or  has  ceased  to  act,  or  whether  it  is  still  present  and  active.  In  chronic 
inflammation  the  most  reliable  indications  of  the  presence  and  potency 
of  the  primary  bacterial  cause  are  acute  exacerbations,  as  chronic  inflam- 
mation only  consists  of  a  series  of  acute  inflammatory  processes  which 
repeat  themselves  at  larger  or  shorter  intef^vals.  The  differences  between 
an  acute  and  chronic  inflammation  are  not  in  kind,  but  in  degree.  The 
complicated  processes  which  characterize  inflammation  can  be  studied 
most  profitabl}^  by  considering  separateh'  and  conjointl}^  the  s3'mptoms 
to  which  they  give  rise,  which  Galen  enumerated  as  calor^  rubor,  dolor  et 
tumor,  to  which  may  now  be  added  the  functio  Isesa  of  modern  authors. 
The  study  of  the  objective  and  subjective  manifestations  of  inflammation 
should  be  preceded  b}'  a  short  description  of 

THE    HISTOLOGICAL    ELEMENTS   WHICH    ARE    DIRECTLY    CONCERNED 
IN    THE   INFLAMMATORY   PROCESS. 

Capillary  Vessels. — The  most  important  histological  changes  in  in- 
flammation, acute  or  chronic,  transpire  within,  and  in  the  immediate 
vicinity  of,  capillar}^  vessels.  The  smallest  arteries  and  veins,  the  ves- 
sels on  either  side  of  the  capillaries,  undergo  changes,  and  the  disturb- 


HISTOLOGICAL   ELEMENTS   IN    THE    INFLAMMATORY   PROCESS.       69 


ance  of  circulation  within  them  constitutes  a  part  of  the  picture  of  in- 
flammation, but  it  is  in  the  capillaries  that  the  most  serious  disturbances 
occur ;  it  is  here  where  the  noxse  are  brought  in  closest  contact  with  the 
para-vascular  tissues,  and  it  is  here  where  the  inflammatorj^  exudation 
and  transudation  take  place.  The  capillaries  are  minute  vessels,  or  rather 
channels,  which  connect  the  arteries  and  veins,  the  walls  of  which  are 
composed  of  a  thin,  elastic,  endothelial  membrane  ;  that  is,  a  single  layer 
of  nucleated  cells  held  together  by  an  amorphous  cement-substance.     In 


Fig.  30.— Capillary  Vessels  of  the  Frog's  Mesexteey,  Stained  with  Ni- 
trate OF  Silver  o>ly;  the  Wall  of  the  Vessel  is  \'iEWEr)  froji  the  Sur- 
face, AND  is  Seen  to  Consist  of  Elongated  Endothelial  Cells,  Marked 
BY  their  Outlines  only  ;  the  Nucleus  of  the  Individual  Cells  is  not 
Shown.    (Klein.) 

silver-stained    specimens    the  cement-substance  appears    as   dark   lines 
which  outline  the  boundaries  of  the  cells. 

The  shape  of  the  cells  is  more  or  less  elongated,  with  pointed  ex- 
tremities, and  their  outline  smooth  or  sinuous.  The  nuclei  of  these  cells 
are  oval,  situated  either  about  the  middle  of  the  cell  or  near  one  ex- 
tremity. The  nucleus  contains  within  a  well-defined  membrane  a  net-work 
of  chromatin  threads,  but  no  nucleolus.  When  the  capillaries  undergo 
alteration  and  distention,  as  in  inflammation,  the  cement-substance  yields 
in  many  places  ;  in  consequence  of  this  minute  openings  appear,  called 
by  Arnold   stigmata,  which   become  gradually  enlarged   into   stomata. 


70  PRINCIPLES   OF    SURGERY. 

Winiwarter  found  that  by  injecting  inflamed  capillaries  the  contents  of 
the  vessel  escaped  through  these  openings.  Through  these  openings 
emigration  of  leucocytes  takes  place,  and  when  the  inflammation  is  very 
intense  the  red  corpuscles  escape, — a  process  which  Strieker  has  named 
diapedesis.  If  the  capillary  vessels,  through  which  emigration  has  been 
going  on,  be  stained  with  nitrate  of  silver,  it  is  seen  that  the  emigration 
is  limited  to  the  interstitial  cement-substance  of  the  endothelial  wall. 
(Purves.) 

Klein  has  shown  that  the  walls  of  all  capillary  vessels  in  the  adult 
state  form  a  direct  connection  with  the  process  of  the  connective-tissue 
corpuscles  of  the  surrounding  tissue, — a  matter  of  great  interest  in 
studying  the  relationship  between  the  capillary  vessels  and  the  sur- 
rounding  connective-tissue  spaces. 

Blood-corpuscles. — The  blood-corpuscles  frequently  serve  as  carriers 
of  the  microbic  cause  of  the  inflammation;  they  block  the  lumen  of 
iutlanied  capillar}^  vessels,  partially  or  completel}', 
and  constitute  the  histological  elements  of  the 
primary  exudation.  The  element  of  the  blood 
which  is  more  intimately  associated  with  the 
histology  of  inflammation  is  the 

I.  Leucocyte,  or  White  Blood-corpuscle. — 
This  is  a  nucleated,  spherical,  transparent  mass 
of  protoplasm,  witliout  a  limiting  membrane  or 
Fig.  31.  — lkucocyte,  envelope.  Heitzmann  made  the  discovery  that 
^oToPL\s>fi"*^^fe^TRiNGs!!  It  Is  couiposcd  of  a  reticulum  of  protoplasmic 
^■^**"'  strings,  with  a  hj^aline  substance  in  the  meshes. 

The  nucleus  shows  a  similar  structure,  and  its  net-work  is  continuous 
with  that  of  the  cell-body.  Strieker  and  Klein,  as  well  as  a  number  of 
other  histologists,  have  adopted  Heitzmann's  views  in  reference  to  the 
minute  anatomy  of  the  leucocyte.  The  reticulated  structure  is  well 
shown  by  staining  with  chloride  of  gold,  which  stains  the  protoplasmic 
strings,  but  not  the  interstitial  substance.  The  leucocyte  is  endowed 
with  intrinsic  power  of  locomotion, — amoeboid  movements, — a  function 
which  is  performed  by  the  reticulum.  Whai'ton  Jones  discovered  motion 
of  protoplasm  in  leucocytes  of  human  blood  as  early  as  1846.  In  1862 
Haeckel  showed  that  the  white  blood-corpuscles  absorb  pigment-granules, 
— a  process  which  can  only  take  place  by  amoeboid  movements,  which  by 
change  of  form  of  cell  bring  the  foreign  material  into  its  interior  by 
inclusion.  These  observations  enabled  Cohnheim  to  demonstrate  later 
that  the  white  blood-corpuscles  found  in  the  vascular  spaces  of  the  cornea 
were  derived  from  the  blood ;  in  other  woi'ds,  to  establish  the  fact  of 
emigration  of  leucocytes  through  the  inflamed  wall  of  capillaries.     The 


HISTOLOGICAL   ELEMENTS   IN    THE    INFLAMMATORY   PROCESS.       71 


amoeboid  movements  of  the  colorless  corpuscles  can  be  well  observed  for 
hours  in  the  moist  chamber  on  the  warm  stage. 

The  movements  of  a  leucocyte  are  peculiar.  The  first  effort  consists 
of  a  protrusion  of  a  hyaline  film.  This  is  withdrawn,  and  another  is 
protruded  ;  in  the  next  moment  this  is  diminished  to  a  very  minute 
process,  whereas,  on  the  opposite  side,  a  new,  broad  process  appears. 
After  this  the  corpuscle  is  seen  to  throw  out  processes  of  various  length 
and  thickness,  and  thus  to  alter  its  shape  in  a  considerable  manner.  By 
virtue  of  the  amoeboid  movement  of  leucocj^tes  they  move  from  place  to 
place  independently  of  the  blood  or  plasma  current.  This  independent 
locomotion  enables  them  to  pass  through  the  small  opening  in  the  wall 
of  inflamed  capillaries,  and,  after  the}'  have  reached  the  para-vascular 
tissues,  to  travel  along  connective- 
tissue  spaces  until  arrested  by 
some  mechanical  obstruction.  If 
pigment-material,  in  a  finely-divided 
state,  is  mixed  with  blood,  either 
before  or  after  withdrawing  it  from 
the  vessels,  the  projections  thrown 
out  by  the  leucocytes  inclose  the 
l)artieles  brought  in  contact  with 
it,  and  the  granules  reach  in  this 
manner  the  interior  of  the  leuco- 
cytes, and  are  variously  distributed 
according  to  the  shape  and  move- 
ments of  the  protoplasm.  Microbes 
reach  the  interior  of  the'  leucoc3'tes 
in  the  same  manner.  In  cases  of 
intra-vascular  infection  the  emigra- 
tion corpuscles  conve\'  with  them 
inflamed  capillaries  into  tlie  tissues  surrounding  them. 

2.  Red  Blood-corpuscle. — The  colored  blood-corpuscle  serves  less 
frequently  as  a  carrier  of  microbes  than  the  leucoc3'te,  as  it  does  not 
possess  amoeboid  movements.  For  the  same  reason  it  is  not  found  so 
constantl}"  as  a  component  part  of  the  inflammatory  exudation,  as  its 
transit  through  the  capillary  wall  is  entirely  a  passive  process,  and  is 
accomplished  only  by  the  vis  a  tergo  in  case  the  stomata  are  sufficiently 
large  to  permit  its  passage.  The  presence  of  numerous  colored  corpus- 
cles in  the  exudation  is  an  indication  of  great  acuity  and  intensity  of  the 
inflammation, — conditions  causing  serious  and  extensive  alterations  of 
the  capillar}'  wall.  The  escape  of  whole  blood  through  a  capillary  vessel 
greatly  damaged  by  the  cause  of  the  inflammation  is  called  rhexis. 


Fig.  32.— Change  of  Fokms  of  a 
Moving  Leucocyte  by  Amceboid  Move- 
ments.   (Klein.) 


the  microbes  through  the  wall  of 


72 


PRINCIPLES   OF    SURGERY. 


3.  Third  Corpuscle. — A  third  cellular  element  in  tlie  blood,  the  third 
corpuscle,  was  discovered  by  Max  Schultze,  in  1865.  He  described  it  as 
a  small,  colorless  sphere  or  granule.  Elaborate  descriptions  of  this 
corpuscle  were  given  by  Hayem,  in  1878,  and  Bizzozero,  in  1882. 
Hayem,  from  his  observations,  believed  that  these  minute  structures 
represented  3'oung  colored  blood-corpuscles,  and  hence  named  them 
hsematoblasts.  Bizzozero  entered  his  protest  against  this  theory  and 
called  them  blood-plates  {Blutpldttchen).  Under  the  microscope  they 
appear    as    minute,   faintly-colored    blood-corpuscles.     They    seem    to 


Fig.  33.     (Eberth  and  Schimmelbusch.) 
1.  Third  corimscle.     A,  natural  appearance  when  seen  on  surface  and  on  edge  :  B.  C,  C,  D.  and  E, 
appearance  presented  by  them  during  coagulation.     2.  Shows  the  little  heaps  of  granules  formed  by  them 
after  coagulation  (Hayem).    3.  A  small  blood-vessel  as  stasia  is  approaching.     A,  third  corpuscles  in 
periphery  of  stream  ;  B,  colored  blood-corpuscles;  C,  leucocyte. 

possess  a  little  stroma  like  the  red  blood-corpuscles,  but  contain  no 
nucleus  and  are  devoid  of  any  cell-membrane.  What  appears  as  a 
nucleus  is,  according  to  Hayem,  an  optical  defect. 

Hayem  estimates  that  they  are  forty  times  more  numerous  in  man 
than  the  leucocytes,  and  twenty  times  more  abundant  than  the  colored 
corpuscles.  As  there  has  been  no  positive  proof  furnished  that  the  third 
corpuscle  is  an  embryonal  red  blood-corpuscle,  and  as  it  has  been  shown 
that  blood-corpuscles  are  produced  from  the  fixed  cells  of  blood- 
producing  organs,  as,  for  instance,  the  spleen  and  medullary  tissue,  it  is 


HISTOLOGICAL   ELEMENTS   IN    THE   INFLAMMATORY   PROCESS.       73 

advisable  not  to  appl}-  to  it  the  term  hsematoblasts,  but  to  designate  it 
from  the  remaining  two  morphological  elements  of  the  blood  numerically 
by  calling  it  the  third  corpuscle.  Under  a  higher  power  the  third 
corpuscle  can  be  readily  recognized  in  the  blood-stream  of  capillary 
vessels  in  the  mesenter^^  or  web  of  a  frog.  In  blood  withdrawn  from  a 
vessel  it  is  destroyed  as  soon  as  coagulation  sets  in ;  hence  it  disappears 
almost  immediately  after  it  leaves  the  blood-vessel.  In  order  to  study  it 
outside  of  the  bod}',  means  must  be  employed  to  prevent  coagulation, 
which  can  be  done  by  mixing  the  blood  with  the  following  solution, 
recommended  b}'  Hayem  : — 

Distilled  water, 200.00  cubic  centimetres. 

Sodic  chloride, 1.00  gramme. 

Sodic  sulphate,        .......  5.00  grammes. 

Mercury  bichloride, 0.50  gramme. 

From  a  needle-puncture  the  blood  is  allowed  to  mix  with  the  solu- 
tion in  the  proportion  of  about  1  to  20  up  to  1  to  100.  In  this  mixture 
the  third  corpuscle  will  retain  its  shape  and  size  for  twelve  to  twenty- 
four  hours.  The  third  corpuscle  is  a  fibrin-producing  structure,  and,  as 
such,  it  takes  an  active  part  in  the  formation  and  growth  of  intra-vascular 
blood-clots.  The  white  mural  thrombus,  produced  intra  vitam,  is  com- 
posed almost  exclusively  of  this  element  of  the  blood.  If,  from  a  trauma 
or  disease  the  endothelial  lining  of  a  blood-vessel  is  injured  and  the 
smooth  surface  becomes  uneven,  the  third  corpuscles,  floating  in  the 
peripheral  portion  of  the  axial  current,  come  in  contact  with  projecting 
points,  and  are  arrested  and  become  attached  to  the  vessel-wall,  laj'er 
after  layer  is  added,  and  in  this  manner  the  mural  thrombus  is  formed. 
On  the  surface  of  recent  wounds  they  appear  in  large  numbers,  lose  their 
fibrin  ferment,  and  give  rise  to  the  formation  of  fibrin,  which  acts  both 
as  a  haemostatic  and  temporary  cement-substance.  In  inflammation  the 
third  corpuscle  escapes  through  the  capillary  wall  in  the  same  manner  as 
the  red  corpuscles,  but,  on  account  of  its  smaller  size,  its  peripheral  loca- 
tion in  the  blood-stream,  and  its  greater  abundance,  it  is  numerically 
more  abundant  in  the  inflammatory  exudation.  The  fibrin  in  inflamed 
tissues  is  undoubtedly  derived  largel}^  from  this  source. 

4.  Fixed  Tissue-cells. — The  fixed  tissue-cells  behave  diflerentl}^  in 
the  inflamed  part,  according  to  the  intensity  and  nature  of  the  primary 
microbic  cause.  The  microbes,  or  their  ptomaines,  may  possess  such 
intense  local  toxic  properties  as  to  destro}^  their  vitalit}'  directl}'  when 
the  inflammation  results  in  necrosis,  as  is  the  case  in  the  centre  of  an 
ordinary  furuncle,  and  on  a  larger  scale  in  cases  of  progressive  phleg- 
monous inflammation.  The  fixed  tissue-cells  may  be  destroyed  by 
starvation,  by  the  primary  inflammatory  exudation  being  so  abundant  as 


74  PRINCIPLES   OF   SURGERY. 

to  obstruct  tlie  circulation  in  the  inflamed  part.  If  the  cause  of  the  in- 
tiannnation  is  less  intense,  as  is  the  case  in  chronic  inflammation,  the 
fixed  tissue-cells  are  brought  in  direct  contact  with  the  microbes  which 
produced  tlie  inflammation,  and  active  tissue  proliferation  is  the  result, 
and  this  furnislies  the  bulk  of  the  inflammatory  product.  The  histo- 
logical structure  of  tubercle  furnishes  a  good  illustration  of  the  part 
taken  by  the  fixed  tissue-cells  in  chronic  inflammation.  In  chronic  sup- 
purative inflammation  the  fixed  tissue-cells  are  first  transformed  into 
embryonal  tissue,  and,  as  the  protoplasm  of  the  new  cells  is  destroyed 
by  the  ptomaines  of  pus-microbes,  they  are  converted  into  pus-corpuscles. 
A  passive  role  in  the  inflammatory  process  was  assigned  to  the  fixed 
tissue-cells  by  Boerhave,  who  regarded  stasis  as  the  essential  feature  of 
inflammation ;  by  Andral,  who  believed  that  hyperaemia  was  the  char- 
acteristic pathological  condition  in  an  inflamed  part;  and  by  Rokitansky, 
who  taught  tliat  exudation  constituted  the  most  important  element  in 
all  inflammator}'  lesions.  Virchow  located  the  primary  seat  of  inflam- 
mation in  the  fixed  tissue-cells,  and  asserted  that  nutritive  or  formative 
irritation  occurred  in  them  independently  of  vessels  or  nerves.  He 
maintained  that  the  more  the  cells  were  disposed  to  take  up  nutritive 
material  the  greater  the  danger  that  they  themselves  would  be  destroyed. 
Remaining  faithful  to  the  doctrine  that  inflammation  is  only  caused  by 
the  presence  and  action  of  a  specific  microbic  cause,  we  shall  find  that 
the  more  acute  the  process  the  less  the  probability  that  the  fixed  tissue- 
cells  take  an  active  part,  and  that  the  more  chronic  the  inflammation  the 
greater  the  amount  of  the  new  material  that  has  been  derived  from  the 
fixed  tissue-cells,  and  the  smaller  the  quantity  of  vascular  exudation. 

SYMPTOMS    OF    INFLAMMATION. 

The  structural  changes  caused  by  inflammation  give  rise  to  a  char- 
acteristic complexus  of  symptoms, — pain,  redness,  swelling,  heat,  and 
suspension, — elimination  or  perversion  of  function.  These  symptoms 
vary  in  intensity,  according  to  the  nature  of  the  primary  cause  and  the 
anatomical  structure  and  location  of  the  tissues  aflfected.  One  or  more 
of  the  symptoms  enumerated  may  be  absent,  when  the  existence  of  in- 
flammation must  be  ascertained  by  a  more  careful  study  of  those  pre- 
sented. In  acute  inflammation  the  S3'mptoms  appear  in  rapid  succession 
or  almost  simultaneous!}^,  while  in  the  chronic  form  the}^  come  on  slowly, 
often  almost  insidiously,  and  frequently  one  or  more  are  wanting,  even 
when  the  disease  which  those  that  are  present  represent  is  far  ad- 
vanced. The  number  and  intensity  of  the  individual  symptoms  vary 
not  only  according  to  the  virulence  of  the  primarj'^  microbic  cause,  but 
are  also  modified  by  the  resisting  capacity  of  the  individual  and  the 


SYMPTOMS    OF   INFLAMMATION.  75 

tissues  affected.  We  speak  of  a  complete  or  partial  immunity  to  certain 
microbic  diseases,  and  of  a  general  or  local,  hereditary  or  acquired,  dis- 
position. For  diagnostic  purposes  the  symptoms  must  be  studied  in- 
dividually and  collectively,  and  with  special  reference  to  their  etiology 
and  the  location  and  structure  of  the  inflamed  tissues  or  organ. 

(a)  Pain. — Pain  is  one  of  the  most  variable  symptoms  of  inflamma- 
tion. It  is  caused  by  traction  or  pressure  to  which  sensitive  nerve-fila- 
ments are  subjected  in  the  inflamed  tissues,  and  probabl}^  also,  in  some 
instances  at  least,  by  extension  of  the  inflammatory  process  to  the 
structure  of  the  nerves  themselves.  Some  patients  are  more  sensitive 
to  pain  than  others.  The  same  extent  and  degree  of  inflammation  of  the 
same  part  giving  rise  to  sensation  of  discomfort  in  a  torpid  person  may 
cause  excruciating  pain  in  patients  with  a  nervous  temperament.  As 
the  degree  of  pain  will  depend  largely  upon  the  number  of  sensitive 
nerves  present  in  the  inflamed  area  and  the  amount  of  exudation,  we 
would  naturally  expect  to  find  pain  a  prominent  symptom  in  inflamma- 
tions of  unyielding  tissue  freely  supplied  by  sensitive  nerves.  This,  as 
a  rule,  is  the  case.  Pain  is  a  distressing  symptom  in  cases  of  phleg- 
monous inflammation  of  the  fascia  and  tendon-sheaths  of  the  fingers  and 
palm  of  the  hand.  Pain  is  the  most  conspicuous  symptom  in  periostitis 
and  inflammation  of  the  serous  membranes.  Wherever  the  inflammatory 
exudation  appears  rapidly  in  parts  freely  supplied  with  sensitive  nerves, 
pain  from  tension  appears  as  one  of  the  foremost  S3fmptoms,  and  con- 
tinues without  intermission  until  tension  is  relieved.  In  acute  suppu- 
ratiA'e  osteom3'elitis  intense  pain  is  present  from  the  very  commencement 
of  the  disease,  and  continues  unabated  until  tension  is  removed  by 
operative  procedures,  or  by  the  escape  of  inflammatory  product,  through 
some  defect  in  the  bone,  into  the  more  3'ielding  paraperiosteal  tissues. 
The  pain  is  throbbing,  sometimes  synchronously,  with  the  pulse  in  acute 
circumscribed  phlegmonous  inflammation.  It  is  sharp  and  lancinating 
in  inflammation  of  serous  membranes.  It  is  described  as  a  burning 
sensation  in  inflammation  of  the  skin.  The  pain  is  of  a  dull,  aching, 
boring  character  in  deep-seated  inflammation,  especially  in  the  interior 
of  bone.  Nocturnal  exacerbation  of  pain  is  a  common  occurrence,  and 
seldom  absent  in  painful  typhlitic  affections.  The  pain  is  not  alwa3''s 
referred  by  the  patient  to  the  seat  of  inflammation,  as  in  the  early  stages 
of  coxitis  it  is  not  in  the  hip,  but  over  the  inner  aspect  of  the  knee,  and 
in  inflammatory  affections  of  the  nerves  the  pain  radiates  along  the  pe- 
ripheral branches,  and  is  usually  felt  most  severely  some  distance  from  the 
seat  of  the  disease.  In  ascertaining  the  existence  and  exact  location  of 
a  deep-seated  inflammation,  tenderness  is  a  more  valuable  sjaiiptom  than 
spontaneous  pain.     Tenderness  is  the  pain  elicited  by  pressure.     If  the 


76  PRINCIPLES   OF    SURGERY. 

inflamed  part  is  tender  on  pressure  and  accessible  to  palpation,  the  area 
of  tenderness  will  correspond  to  the  extent  of  the  inflammation.  During 
the  beginning  of  an  attack  of  phlegmonous  inflammation  the  surgeon  is 
able  to  locate  the  affection  accuratel}^,  by  searching  for  the  point  where 
the  tenderness  is  most  acute,  and  the  same  symptom  will  indicate  to  him, 
earlier  than  any  other,  the  direction  in  which  the  process  is  extending. 
In  periostitis  the  area  of  tenderness  will  show  whether  the  inflammation 
is  circumscribed  or  diffuse.  The  existence  of  circumscribed  points  of 
tenderness  about  the  epiphyses  of  the  long  bones  is  almost  a  certain  in- 
dication of  central  osseous  tuberculosis,  and,  at  the  same  time,  furnishes  a 
reliable  guide  in  their  early  operative  treatment.  Firm  pressure  relieves 
pain  in  nervous  hysterical  patients,  while  it  aggravates  it  when  it  is 
caused  by  inflammation.  On  the  other  hand,  superficial  pressure  made 
with  the  tips  of  tlie  fingers  increases  the  suffering  in  parts  the  seat 
of  functional  disturbance,  while  it  does  not  materially  affect  the  pain 
resulting  from  inflammator}'  lesions. 

(b)  Redness. — The  composition  of  normal  blood  is  admirably 
adapted  for  the  passage  of  this  fluid  through  capillary  vessels.  As  long 
as  the  relation  of  corpuscular  elements  to  the  blood-plasma  remains 
normal,  and  the  intima  of  the  blood-vessels  remains  intact,  and  the  vis  a 
tergo  is  adequate,  there  is  no  tendency  to  capillary  obstruction.  If  the 
capillary  circulation  in  the  mesentery  of  a  frog  is  examined  under  a 
microscope,  there  is  no  difficult}^  in  distinguishing  two  currents, — the 
axial  and  peripheral.  The  axial  or  central  current  is  rapid  and  conveys 
the  red  corpuscles,  which  have  the  same  specific  gravity  as  the  blood- 
plasma,  while  the  peripheral  current  between  the  axial  and  vessel-wall 
is  considerably  slower,  and  in  this  current  the  colorless  corpuscles  are 
conveyed,  their  rotating  motion  being  due  to  their  coming  in  contact 
with  the  wall  of  the  vessel.  D.  J.  Hamilton  has  shown,  by  numerous 
experiments,  that  in  fluids  holding  in  suspension  solid  particles  passing 
through  capillary  tubes  the  heaviest  particles  are  carried  along  the 
central  current,  while  those  specifically  lighter  than  the  fluid  seek  the 
periplieral  current.  The  leucoc3'tes  are  specificall}^  lighter  than  the  fluid 
in  which  they  are  contained  ;  hence  they  are  forced  into  the  space  be- 
tween the  axial  current  and  the  vessel-wall  (Fig.  33,  C).  The  third  cor- 
puscle, probabl}^  for  the  same  reasons,  moves  also  in  the  peripheral 
stream.  Tlie  colorless  corpuscles  accumulate  more  in  the  peripheral 
stream  when  the  current  is  feeble  than  when  it  is  rapid.  This  fact  is  of 
great  importance  in  the  study  of  the  altered  circulation  when  the  capil- 
lary vessels  are  in  a  state  of  inflammation.  The  accumulation  of  color- 
less corpuscles  in  the  peripheral  stream  in  inflamed  capillary  vessels, 
according  to  Thoma,  Eberth,  and  Schimmelbusch,  is  owing  to  the  slow- 


SYMPTOMS   OF   INFLAMMATION.  77 

ness  of  the  current,  "which,  although  insufficient  to  propel  the  specifically 
light,  colorless  corpuscles,  is  still  competent  to  force  onward  the  less- 
resisting  and  specificall}^  heavier-colored  corpuscles. 

Eberth  and  Schimmelbusch  state  that  in  the  vessels  of  a  warm- 
blooded animal  four  kinds  of  stream  are  noticed,  in  accordance  with  its 
velocity:  (1)  tlie  normal  stream,  in  which  the  axial  current  and  periph- 
eral zone  are  readil}-  recognizable ;  (2)  a  slow  stream,  in  which  the 
leucoc3'tes  accumulate  in  the  periphery;  (3)  a  still  slower  stream,  in 
which  the  third  corpuscles  also  leave  the  axis  and  accumulate  in  the 
peripher}',  and  in  wliich,  these  observers  assert,  the  leucocytes  become 
less  numerous  ;  and  (4)  a  stream  so  slow  as  to  approach  stagnation,  in 
which  all  the  elements  of  the  blood  are  indiscriminately  mixed.  From 
the  above  it  can  be  seen  that  all  general  and  local  conditions  which  tend 
to  diminish  the  velocity  of  the  blood-current  in  the  capillary  vessels  are 
productive  of  accumulation  of  the  colorless  corpuscles  and  of  the  third 
corpuscle  in  the  peripheral  stream, — a  condition  which  greatl}' aggravates 
the  existing  local  impediments  to  capillary  circulation,  and  when  well 
advanced,  by  encroaching  more  and  more  upon  the  central  stream,  will 
result  in  complete  stasis.  Redness  as  a  s3nnptom  of  inflammation 
signifies  an  excess  of  blood  in  the  part,  and  the  terms  used  to  indicate 
its  existence  are  hj'persemia  and  congestion,  while  complete  arrest  of  the 
capillary  circulation  is  expressed  by  the  word  stasis.  Accurately  speak- 
ing, hy2:)e7^8emia  should  be  used  to  designate  that  condition  of  the  circu- 
lation where  the  part  not  onl}^  contains  an  increased  amount  of  blood, 
but  where  an  increased  amount  of  blood  fiows  to  and  returns/ro??i  the  part, 
— an  exalted  physiological  process ;  while  the  word  congestion  literally 
means  onl}-  an  accumulation  of  blood  in  a  part, — a  condition  owing  to 
some  form  of  local  or  distant  mechanical  obstruction.  The  condition 
giving  rise  to  redness,  hyperaemia,  congestion,  and  stasis  should  not  be 
studied  onl}^  from  descriptions,  but  in  order  to  be  understood  they 
should  be  seen.  This  can  be  readily  done  b}^  producing  artificially  an 
inflammation  in  a  transparent  part  of  some  lower  animal,  preferably  the 
frog,  and  studying  the  circulation  in  the  inflamed  part  step  b}^  step 
under  the  microscope.  For  this  purpose  experimenters  have  usually 
selected  the  frog's  web,  mesenterj",  tongue,  lung,  and  bladder,  and  the 
tadpole's  tail.  For  general  use  the  frog's  web  should  be  selected,  as  the 
preparations  for  this  experiment  are  ver}^  simple.  Inflammation  is 
provoked  by  cauterizing  the  web  with  a  needle  heated  to  a  red  heat,  or 
by  appl3'ing  with  a  small  plug  of  cotton  some  powerful  irritant,  as 
ammonia,  tincture  of  cantharides,  or  croton-oil,  or  by  touching  the 
surface  with  a  sharp  stick  of  nitrate  of  silver.  Hamilton  gives  the 
following   directions   for  making   the   experiment :  "  Nothing   more  is 


78 


PRINCIPLES   OF    SURGERY. 


necessary  than  a  piece  of  tin  or  other  soft  metal,  about  1^  to  2  inches 
broad  and  about  6  to  8  inches  long,  or,  what  is  better,  a  thin  piece  of 
hard  wood  of  the  same  dimensions.  At  the  end  Avliere  the  web  is  to  be 
stretched  it  should  not  be  so  broad.  From  tlie  narrow  end  of  this  a 
V-shaped  piece  is  cut  out,  over  whicli  the  web  is  to  be  spread.  Tlie  frog 
should  lirst  ])e  curarized,  as  tliis  does  not  interfere  with  the  circulation, 
provided  that  the  solution  employed  be  not  too  strong.  The  ^oVir  of  a 
grain,  in  watery  solution,  injected  under  the  skin,  is  sufficient.  Chloral 
may  be  substituted.  Caton  recommends  a  solution  of  4  grains  to  the 
drachm.     As  many  minims  should   be   injected   subcutaneousl}^  as  the 


Fig.  34.— Normal  Circtjlation  in  Frog  i  "\\  eb     {Landercr.) 

A,  artery;  B,  vein;  C,  capillaries.    Vessels  c  vered  by  a  net  «oik  of  i  olygonal  epithelial  cells  of  web,  in 

which  pigmented  cells  are  not  represented. 

frog  is  drachms  in  weight.  The  injection  is  made  under  the  skin  of 
the  back  with  an  ordinary  hypodermic  syringe.  The  animal  is  laid  on 
the  piece  of  metal  or  wood,  and,  the  web  being  stretclied  over  tlie  cleft 
at  the  end,  the  toes  are  held  by  tying  a  piece  of  thin  thread  to  them  and 
fixing  the  ends  into  a  fine  slit  cut  in  the  metal  or  wood."  Tlie  micro- 
scope is  so  arranged  and  adjusted  that  the  field  of  observation  will  cor- 
respond to  the  point  of  irritation,  A  suflficiently  high  power  is  used  so  that 
the  different  corpuscular  elements  in  the  capillary  stream  can  be  readily 
seen  and  recognized.  In  order  to  witness  the  different  stages  of  the  in- 
flammatory process  it  is  necessar}'  to  continue  the  observation  for  hours. 


SYMPTOxMS   OF   INFLAMMATION, 


79 


Any  one  of  the  irritants  mentioned  applied  to  tlie  frog's  web  will 
produce  in  the  capillaries  over  a  limited  area  a  series  of  changes  which 
are  always  present  in  inflammation,  and  a  description  of  them  will  repre- 
sent what  takes  place  in  capillaries  the  seat  of  inflammatory  process  of 
bacterial  origin  ;  almost  simultaneously  with  the  application  of  the 
irritant  a  momentary  contraction  of  the  A^essel  occurs,  caused  by  the 
stimulation  of  the  vaso-contractor  nerves,  which  is  followed  b}'  dilata- 
tion, with  increased  velocit}^  of  the  capillary  current, — a  true  hyperemia. 
The  bright-red  color  of  the  hyperajmic  i)art  at  tliis  stage,  according  to 


liT/w/i^ 


Fig.  35.— Capillakies  of  Frogs  Web  in  a  State  of  Hyperemia  soon  after 
Application  of  Irritant.    {Landerer.) 

A,  artery ;  B,  vein ;  0,  capillaries. 

Recklinghausen,  is  due  to  increase  in  the  rnpidity  of  the  blood-current, 
but,  as  the  color  of  the  blood  indicates  a  diminished  expenditure  of 
oxygen  and  a  smaller  quantity  of  carbon  in  tlie  blood,  increased  velocitj- 
alone  would  not  explain  this  change.  Diminished  alkalescence  in  the 
inflamed  tissues  may  reduce  the  amount  of  oxygen  used,  as  is  the  case 
in  glands  during  active  secretion,  where  Claude  Bernard  showed  that 
defective  ox3^genation  is  always  present.  At  this  stage  the  corpuscular 
elements  circulate  in  their  respective  streams,  and  the  whole  picture  is 
one  of  increased  physiological  activity.  Dilatation  of  the  vessels  follows 
contraction  so  quickly  that  it  would  be  diflRcult  to  explain  it  as  a  para- 


80  PRINCIPLES   OF   SURGERY. 

h  tic  phenomenon.  Its  early  ontset  and  the  rapidity  with  which  it  ap- 
pears would  point  to  a  neurotic  cause,  traceable  to  the  action  of  ganglia 
in  the  vessel-wall.  It  has  not  yet  been  satisfactoril}'  explained  whetlier 
this  early  dilatation  of  the  vessel  is  due  to  vasomotor  paralysis  or 
irritation  of  the  vaso-dilators,  but  it  is  more  pro])ab]e  that  it  is  caused 
b\'  the  vaso-dilators,  while,  later,  paral3'sis  from  overdistention  occurs. 
Division  of  the  sympathetic  in  the  neck  brings  about  increased  vascu- 
larity, but  no  inflammation.  The  difference  between  dilatation  of  an 
inflamed  vessel  and  the  dilatation  following  division  of  the  S3'mpathetic 
consists  in  alteration  of  the  capillary  wall,  in  the  former  instance  pro- 
duced by  the  action  of  the  causes  wliich  induced  the  inflammation,  while 
in  the  latter  the  dilatation  is  a  purely  nervous  phenomenon,  unattended 
b}^  other  pathological  conditions  of  the  vessel-wall.  Disturbances  of  the 
circulation  alone  are  not  sufficient  to  bring  about  the  local  changes  which 
are  characteristic  of  inflammation  ;  if  the  velocity  of  the  blood-current 
is  greatly  diminished  by  purely  mechanical  or  nervous  causes,  mural 
implantation  of  the  white  corpuscles  maj'^  take  place,  but  emigration 
does  not  occur  on  account  of  the  absence  of  the  essential  condition 
which  gives  rise  to  it, — alteration  of  the  capillary  wall. 

Dilatation  is  first  noticed  in  the  smallest  arteries,  afterward  in  the 
veins  and  capillaries,  and  keeps  increasing  from  fifteen  minutes  to  two 
hours.  The  vessels  often  enlarge  to  double  their  normal  calibre.  During 
the  stage  of  dilatation  man}'  of  the  capillaries  which  were  small  or  con- 
tained but  little  ])lood  become  visible,  which  greatl}'  adds  to  the  turgidity 
and  redness  of  the  inflamed  part.  As  long  as  the  acceleration  of  the 
capillary  current  continues,  the  different  corpuscles  move  in  their  respec- 
tive currents.  The  white  corpuscles  that  are  mingled  with  the  colored 
are  washed  along  with  the  latter  in  the  central  stream  without  finding 
their  way  into  the  sloAver  side-current  which  propels  the  leucocj^tes  and 
the  third  corpuscles.  The  leucocytes  in  the  peripheral  stream  appear 
more  numerous,  and  skip  along  by  more  rapid  rotator}^  movements.  At 
this  time  the  circulation  has  reached  its  greatest  speed,  and  the  tissues 
present  every  appearance  of  well-marked  hyperemia.  In  from  fifteen 
minutes  to  two  hours  from  the  time  the  irritant  was  applied,  intra-vascular 
changes  are  noticed  which  are  calculated  to  impede  the  capillary  current. 
The  first  link  in  the  chain  of  local  causes  which  obstruct  the  capillary 
circulation  consists  of  a  crowded  condition  of  the  vessels  from  a  greater 
accumulation  of  the  different  corpuscles,  which  is  soon  followed  by  a 
greater  separation  of  the  leucocytes  from  the  central  current  and  their 
greater  accumulation  in  the  peripheral  stream,  where  they  often  become 
arranged  in  heaps  and  little  masses.  This  change  is  first  observed  in  the 
small  veins,  and  somewhat  later,  and  to  a  lesser  extent,  in  the  smallest 


SYMPTOMS   OF   INFLAMMATION.  81 

arteries.  Separation  of  tlie  blood-corpuscles  is  the  necessary  outcome 
of  slowing  of  the  stream  from  greater  accumulation.  In  the  peripheral 
zone  of  leucocytes  the  next  source  of  obstruction  is  created.  Some  of 
the  colorless  corpuscles  become  momentarily  attached  to  the  capillarj'^ 
wall,  when  they  are  again  detached  by  the  force  of  the  current,  or  are 
rolled  away  by  another  leucocyte.  As  the  process  adA'ances  it  appears 
as  though  the  viscosity  of  the  leucocjtes  was  increasing  constantl}',  as 
more  and  more  of  them  become  adherent,  while  fewer  are  again  detached. 
The  lumen  of  the  vessel  is  narrowed  more  and  more  by  mural  implanta- 
tion of  the  leucocytes.  The  small  veins  now  assume  an  appearance  as 
if  the  internal  surface  of  their  wall  were  paved  with  leucocytes,  while  in 
the  capillaries  a  similar  adhesion  of  the  leucocytes  to  the  wall  is  noticed. 
At  this  stage  it  often  appears  as  though  complete  obstruction  would 
occur  everj'  moment,  the  capillary  stream  becoming  completely  arrested 
for  a  moment,  and  the  current  may  even  move  in  an  opposite  direction, 
when  the  obstruction  is  again  overcome  and  the  current  moves  once  more 
in  the  right  direction.  The  smallest  arteries  exert  themselves  to  the 
utmost  to  clear  the  way,  and  pulsations  can  be  seen  where  in  a  normal 
condition  thej'^  are  absent.  Hypersemia  has  now  given  way  to  congestion. 
An  intra-vascular  obstruction  has  given  rise  to  accumulation  of  blood  on 
the  proximal  side  of  the  inflamed  vessel.  Increasing  slowing  of  the 
current  gives  rise  to  greater  accumulation  of  leucocytes,  which  become 
firmly  adherent  to  the  capillary  wall,  narrowing  the  vessel  more  and 
more  until  the  space  for  the  axial  current  becomes  too  small  for  the  pass- 
age of  the  red  corpuscles,  when  complete  arrest  of  the  circulation  takes 
place.  Congestion  has  resulted  in  stasis.  As  soon  as  complete  stasis 
has  taken  place  the  colorless  corpuscles  become  mixed  with  the  red  cor- 
puscles which  are  forced  into  the  mass  of  the  white,  while  by  amoeboid 
moA'ements  the  latter  wander  toward  the  centre  of  the  vessel  and  mix 
freely  with  those  which  were  moving  in  the  central  current.  The  most 
advanced  stages  of  vascular  disturbance  are,  of  course,  noticed  first  where 
the  irritant  was  applied,  so  that  when  complete  stasis  has  taken  place  in 
the  centre  a  zone  of  congestion  surrounds  this,  while  more  distant  ves- 
sels still  present  every  indication  of  actiA'e  hyperjemia.  Redness  is  most 
marked  where  hypersemia  is  extant ;  that  is,  in  parts  containing  a  maxi- 
mum amount  of  arterial  blood.  As  soon  as  congestion  sets  in,  the  blood- 
corpuscles,  red  and  white,  do  no  longer  pass  through  the  vessel  with  the 
same  rapidity  and  number,  and  the  redness  gives  way  to  a  bluish  tinge, 
wliich  becomes  well  marked  and  does  not  give  way  to  pressure  when 
complete  stasis  has  occurred.  The  blood  in  the  stagnated  vessels,  accord- 
ing to  Paget,  has  little  tendency  to  coagulate  ;  hence  the  possibility  of 
resistutio  ad  integrum  of  the  circulation  after  subsidence  of  the  acute 

6 


82  PRINCIPLES   OF   SUKGERY. 

symptoms.  Complete  stasis  occurs  first  in  such  capillaries  where  the 
vis  a  tei-go  is  greatly  diminislied  by  a  circuitous  route  from  an  artery  to 
a  vein,  and  increases  in  the  direction  in  which  the  blood-current  is 
slowest.  In  warm-blooded  animals  the  phenomena  of  inflammation  do 
not  differ  materially  from  those  observed  in  the  frog's  web,  except  as  re- 
gards the  presence  and  disposition  of  the  third  corpuscles.  According 
to  Eberth  and  Schimmelbusch,  in  warm-blooded  animals  the  third  cor- 
puscles in  the  normal  capillary  circulation  move  along  with  the  colored 
corpuscles  in  the  axial  current,  and  hence  they  maintain  that  they  must 
be  of  nearly  the  same  specific  gravity.  A  few  of  the  leucocytes,  mixed 
with  the  colored  corpuscles  and  the  third  corpuscles,  are  found  in  the 
central  stream,  but  the  majority  of  them  are  propelled  by  the  peripheral 
stream,  which,  according  to  those  observers,  is  from  ten  to  twenty  times 
slower  than  the  central  or  axial  current.  With  the  slowing  of  the  stream 
from  alteration  of  the  capillary  wall  and  subsequent  intra-vascular  condi- 
tions, separation  of  the  corpuscles  takes  place  in  the  same  manner  as 
has  been  described  in  the  frog's  web ;  the  leucocytes  and  third  corpuscles 
leave  the  central  stream  and  accumulate  in  the  slower  peripheral  zone  of 
capillary  stream,  where  they  give  rise  to  a  greater  degree  of  slowing  of 
the  column  of  blood  by  the  formation  of  intra-vascular  obstruction,  which, 
if  suthcient  in  degree,  finally  arrests  the  central  current,  thus  causing 
stasis.  The  inflammatory  process  in  warm-blooded  animals  can  be  studied 
advantageously  in  the  artificially-inflamed  omentum  of  young  animals, 
especially  the  guinea-pig,  as  the  omentum  in  these  animals  is  exceedingly 
delicate  and  transparent.  The  animal  is  narcotized  by  injecting  sub- 
cutaneously  3  grains  of  hydrate  of  chloral  for  a  full-grown  animal.  As 
the  animal,  with  the  exception  of  the  head,  is  to  be  kept  immersed  in  a 
physiological  solution  of  salt  kept  at  a  temperature  of  the  body  in  a  large 
vat  with  a  glass  bottom,  it  is  wrapped  in  a  sheet  of  gutta-percha  tissue 
long  enough  to  overlap  the  head,  and  made  so  as  to  inclose  a  funnel-like 
space  through  which  it  may  breathe.  An  opening  is  made  in  the  cover- 
ing at  a  point  corresponding  to  the  abdominal  incision,  tlirough  which 
the  omentum  is  withdrawn.  Tlie  object-glass  of  the  microscope  is  im- 
mersed in  the  solution,  and  the  omentum  laid  over  a  slide  without  fasten- 
ing it.  The  vat  is  made  so  that  it  will  fit  on  to  the  stand  of  an  ordinary 
microscope,  so  tliat  the  light  can  be  readily  adjusted.  Two  tubes,  one 
to  conve}'  the  salt  solution  into  the  vat  and  another  to  conduct  it  away, 
are  attached  at  opposite  sides.  These  can  be  connected  with  a  vessel 
whose  temperature  is  kept  constant  by  means  of  a  thermostat  and  Bunsen 
burner. 

(c)  Swelling. — The  primary  swelling  in  inflammation  is  due  to  dila- 
tation of  blood-vessels,  and  its  degree  will  depend  on  the  vascularitv  of 


SYMPTOMS    OF    INFLAMMATION.  83 

the  part  inflamed.  The  more  numerous  the  blood-A'essels,  the  greater  the 
swelling  from  this  cause.  As  the  inflamed  blood-vessels  will  often  dilate 
within  two  hours  to  double  their  normal  calibre,  the  primary  swelling  in 
vascular  organs  in  a  state  of  acute  inflammation  will  come  on  quickly, 
and  will  give  rise  to  a  not  inconsiderable  enlargement  of  the  inflamed 
part.  If  during  this  stage  of  inflammation  the  tissues  are  incised, 
hemorrhage  is  profuse,  and  the  emptying  of  turgid  blood-vessels  by  this 
means  has  a  prompt  eft'ect  in  diminishing  the  swelling.  Nancrede  has 
shown  by  his  investigations  that  local  depletion,  during  the  hyperaemic 
stage  of  inflammation,  exercises  a  favorable  influence  in  unloading  the 
distended  blood-vessels  and  in  modifying  the  intensit}^  of  the  subse- 
quent conditions  in  the  inflamed  tissues.  It  is  also  during  this  stage 
that  the  application  of  cold  proves  a  beneficial  resource  in  the  treatment 
of  acute  inflammation,  as  under  its  effects  the  distended  blood-vessels 
contract,  and  in  consequence  of  the  diminution  of  the  vascularit}'  of  the 
inflamed  part  the  primary  inflammator}'  swelling  is  diminished. 

I.  Inflammatory  Exudation. — A  moderate  amount  of  swelling  is 
present  in  all  regenerative  processes,  as  dilatation  of  the  vessels  neces- 
sarily precedes  the  increased  physiological  activit}'  of  the  tissue,  and  the 
embryonal  material  required  in  the  reparative  process  occupies  a  larger 
volume  than  the  mature  tissue  it  is  intended  to  replace.  Inflammation 
is  characterized  by  tlie  presence  of  a  superabundance  of  cells.  The  cause 
which  has  produced  the  inflammation  has,  b}^  its  direct  action  upon  the 
capillary  wall,  produced  such  alterations  of  its  structure  as  to  render  it 
more  porous,  hence  permeable  to  the  passage  of  the  inclosed  cellular 
elements  of  the  blood.  The  albuminous  cement-substance  which  holds 
together  the  endothelial  cells  disintegrates  at  diflerent  points,  and 
through  these  small  defects,  the  stigmata  and  stomata,  the  blood-cor- 
puscles find  their  wa}^  through  the  capillar}^  wall  into  the  surrounding 
l3-mph  and  connectiA'e-tissue  spaces.  In  acute  inflammation  the  inflam- 
matory exudation  consists  principall}'  in  the  extra-vascular  accumulation 
of  blood-corpuscles  which  have  passed  through  the  injured  capillary 
wall.  The  rapidity  with  which  the  inflammatory^  exudation  appears  will 
depend  on  the  intensity  of  alteration  of  the  capillary  wall  and  the  speed 
with  which  the  blood-corpuscles  escape  into  the  surrounding  tissues. 
In  chronic  inflammation  exudation  takes  place  slowly,  and  the  histological 
elements  of  the  inflammatory  swelling  are  derived  mostly  from  the  fixed 
tissue-cells. 

Emigration  of  Leucocytes. — The  passage  of  a  leucocyte  through  a 
defect  in  the  capillary  w'all  is  called  emigr.ation, — the  wandering  of  such  a 
cell  from  a  place  where  it  has  a  normal  existence  into  a  territor}'^  where, 
in  a  condition  of  health,  it  is  seldom  met  with.     After  it  has  made  its 


84  PRINCIPLES   OF   SURGERY. 

escape  from  the  capillary  vessel  it  is  called  an  emigration  or  wandering 
corpuscle.  John  Hunter  came  very  near  being  the  discoverer  of  emigra- 
tion of  leucocytes  during  his  researches  on  inflammation.  He  incised 
the  tunica  vaginalis  in  animals,  and  inserted  a  tallow  plug,  which  he 
removed  after  short  intervals,  and  examined  the  fluid  upon  its  surface 
under  the  microscope.  He  found  in  this  fluid,  a  short  time  after  the  in- 
cision was  made,  round,  white  cells,  which  could  have  been  nothing  else 
but  wandering  leucocytes. 

The  credit  for  having  demonstrated  the  porosity  of  the  capillary 
wall  and  the  escape  of  the  colorless  corpuscles  unquestionably  belongs  to 
Waller.  This  author  observed  emigration  in  the  tongue  of  the  frog  as 
early  as  1846,  and  strongly  maintained  that  the  inflammatory  exudates 
were  composed  largely  of  leucocytes,  in  opposition  to  the  blastema  theory 
of  formation  of  pus  and  other  inflammatory  products. 

In  1849  Addison  clearly  pointed  out  the  relationship  of  the  color- 
less corpuscles  and  the  corpuscles  lying  around  the  vessel  in  inflamed 
parts,  as  becomes  evident  from  the  following  sentences  from  his  work  on 
"Consumption  and  Scrofula:"  "During  inflammation — using  the  word 
in  the  general  sense  here  indicated — there  is  more  or  less  marked  increase 
of  the  colorless  elements  and  protoplasm  in  the  part  affected.  At  first 
— in  the  first  stage — these  elements  adhere  but  slightly  along  the  inner 
margin  or  boundary  of  the  nutrient  vessels,  and  are  therefore  still  within 
the  influence  of  the  circulating  current,  belonging,  as  it  were,  at  this 
period  as  much,  or  rather  more,  to  the  blood  than  to  the  fixed  solid. 
Secondly — in  the  second  stage — they  are  more  firmly  fixed  in  the  walls 
of  the  vessels,  and,  therefore,  now  without  the  influence  of  the  circu- 
lating current.  Thirdly" — in  the  third  stage — new  elements  appear  at  the 
outer  border  of  the  vessels,  where  they  add  to  the  texture,  form  a  new 
product,  or  are  liberated  as  an  excretion." 

Recklinghausen  found  wandering  corpuscles  in  the  vascular  spaces 
of  tlie  cornea,  but  he  believed  that  they  were  a  product  of  tissue  pro- 
liferation from  the  fixed  corneal  corpuscles.  Our  modern  knowledge  of 
emigration  of  leucocytes  is  founded  almost  exclusively  upon  the  labors 
of  Cohnheim.  This  observer  demonstrated,  in  the  j'ear  1867,  by  his 
own  ingenious  experiments,  that  the  wandering  corpuscles  discovered  by 
Recklinghausen  in  the  vascular  spaces  of  the  cornea  were  leucocytes 
which  had  escaped  from  capillary  vessels  and  had  wandered  into  the 
cornea.  He  based  his  statements  on  the  results  of  an  experiment  which 
could  leave  no  room  for  discussion.  He  injected  finely-divided  pigment- 
material  directly  into  the  circulation  of  an  animal,  and  somewhat  later 
produced  artificially  a  keratitis.  In  examining  the  cornea  he  found  the 
vascular  spaces  nearest  the  margin  of  the  cornea  crowded  with  leuco- 


SYMPTOMS   OF   INFLAMMATION.  85 

cytes  loaded  with  pigment-granules.  There  could  be  only  one  conclu- 
sion,— that  the  leucocytes,  which  had  become  charged  with  pigment- 
granules  in  the  general  circulation,  had  passed  through  the  capillary 
vessels  at  a  point  nearest  the  seat  of  irritation ;  in  other  words,  the 
capillary  vessels  which  took  part  in  the  traumatic  keratitis  furnished 
the  primary  inflammatory  exudation.  A  slight  irritation  of  a  frog's 
webb  will  onl}'  produce  an  active  Ii3'per8emia,  and  in  a  short  time  the 
circulation  returns  to  normal  without  any  emigration  of  leucocj'tes 
having  taken  place.  In  such  cases  the  irritant  has  been  of  such  a 
nature  or  of  such  mild  action  as  not  to  produce  the  necessary  alteration 
of  the  capillary  wall  for  mural  implantation  and  emigration  to  take 
place. 

Zahn  has  shown  that  if  the  mesentery  of  an  animal  is  exposed,  but 
carefully  protected  against  injury,  emigration  of  leucocytes  does  not 
take  place  for  seven  or  eight  hours,  while  the  remaining  disturbances  of 
the  circulation  indicate  the  existence  of  inflammation.  If,  however,  the 
frog's  web  or  tongue  is  cauterized  with  a  sharp-pointed  pencil  of  nitrate 
of  silver  the  necessary  conditions  for  an  acute  inflammation  are  created, 
and  the  minute  eschar  is  soon  surrounded  by  vessels  showing  the  differ- 
ent stages  of  the  inflammatory  process,  from  active  l^-persemia  to  com- 
plete stasis.  Emigration  of  leucocytes  takes  place  most  actively  in 
capillaries  partly  obstructed  by  mural  aggregation  of  these  elements,  and 
the  process  is  arrested  as  soon  as  the  circulation  has  come  to  a  complete 
standstill.  The  following  conditions  must  be  present  and  are  essential 
for  emigration  of  leucocytes  :  1.  Alteration  of  capillary  wall.  2.  Mural 
implantation  of  leucoc3'tes.  3.  Permeability  of  lumen  of  capillary  vessel. 
4.  Amoeboid  movements  of  leucoc_ytes, 

1.  Alteration  of  capillary  wall  has  been  repeatedlj''  enumerated  as 
the  most  important  feature  of  inflammation,  and  without  such  a  change 
the  rapid  escape  of  leucocj^tes  as  we  find  it  in  inflammation  would  be 
utterlj^  impossible.  The  cause  which  has  produced  the  inflammation 
produces  such  a  degree  of  softening  in  the  cement-substance  as  to  enable 
its  penetration  by  the  leucocytes  between  the  endothelial  cells,  or,  as  some 
of  the  authors  claim,  localized  minute  defects  cause  the  formation  of 
small  openings  through  which  the  leucoc,ytes  escape. 

2.  Mural  implantation  of  leucocj'tes  is  an  equally  essential  condition, 
as  without  it  the  leucocytes,  which  are  at  any  rate  larger  in  circumference 
than  the  supposed  openings  through  which  they  escape,  would  be  rolled 
over  these  minute  defects  b}^  the  sluggish  peripheral  stream, and  emigra- 
tion would  not  take  place.  Increased  adhesiveness  or  viscosit}'  of  the 
leucocytes  is  supposed  to  play  an  important  part  in  the  occurrence  of 
mural  implantation.     According  to  Hering,  mural  fixation  of  the  leuco- 


86 


PRINCIPLES   OF    SURGERY. 


cytes  is  effected  by  fine  projections,  which  are  thrown  out  on  their  sur- 
face, and  which  insinuate  themselves  into  the  small  crevices  of  the  rough- 
ened intima.  Mural  implantation  cannot  take  place  as  long  as  the  capil- 
lary stream  retains  its  normal  velocity  ;  hence,  slowing  of  the  peripheral 
current  is  the  first  and  most  important  cause.  The  slower  the  peripheral 
stream,  the  more  readily  does  mural  implantation  occur,  and  the  greater 
the  tendency  to  aggregation  of  leucoc^^tes  along  and  near  the  capillary 
wall.  The  rapid  tra^isudation  of  the  plasma  of  the  blood  through  the 
defective  capillary  is  undoubtedly  another  cause  of  impediment  of  prog- 
ress and  final  adhesion  of  leucocytes  to  the  inner  surface  of  the  capil- 
lary vessel.  Finally,  mural  fixation  of  leuco- 
cj^tes  is  effected  by  the  changed  condition  of 
the  protoplasm  of  the  leucocytes  and  the  inner 
surface  of  the  capillary  wall  by  the  action  of 
the  essential  cause  which  produced  the  inflam- 
mation. 

3.  It  has  been  shown  that  emigration  of 
leucocytes  is  most  active  where  the  capillary 
circulation  has  become  impeded,  but  not  ar- 
rested, and  that  the  process  is  arrested  with  the 
occurrence  of  complete  stasis ;  hence,  it  ap- 
pears that  the  intra-vascular  pressure  is  one 
of  the  factors  in  this  process.  Hering  and 
Schklarewsky  maintained  that  the  leucocytes 
are  entirely  passive  structures  in  their  passage 
through  the  capillary  wall,  that  they  are  forced 
through  defects  in  the  wall  exclusively  l\y  the 
intra-vascular  pressure.  That  emigration  is  not 
such  a  simple  process  is  evident,  as  there  would 
be  in  such  case  a  larger  representation  of  colored 
corpuscles  in  the  inflammatory  exudation.  The 
blood-pressure  assists  in  the  extrusion  of  leuco- 
cytes that  have  penetrated  the  capillary  wall,  but,  without  changes  in 
their  form,  would  not  be  adequate  to  force  them  through  the  minute 
openings  or  the  softened  cement-substance. 

4.  Leucocytes,  in  order  to  pass  tlirough  an  inflamed  capillary  wall, 
must  possess  amoeboid  movements  ;  hence,  onl}^  living  leucoc^^tes  are 
capable  of  migration. 

After  the  leucocyte  has  become  implanted  upon  the  inner  surface 
of  the  capillary  wall  it  penetrates  the  softened  cement-substance  by 
throwing  out  projections,  or  one  of  these  projections  insinuates  itself 
into  one  of  the  minute  foramina,  and  as  the  intra-mural  portion  increases 


Fig.  36.— Leucocyte  Pass- 
ing THROUGH  Capillary 
Wall.     (Landerer.) 

A,  leucocyte  attached  to  capillary 
wall  ijy  delicate  processes ;  higher  up 
it  has  penetrated  the  capillary  wall  by 
a  large  projection  ;  B,  half  of  the  leuco- 
cyte outside  of  the  capillary  wall  drag- 
ging the  balance  after  it. 


SYMPTOMS   OF   INFLAMMATION.  87 

in  size  the  balance  of  the  leucocyte  is  drawn  toward  it ;  this  step  is 
greatl}^  aided  by  the  blood-pressure,  which  pushes  the  intra-vascular  por- 
tion in  the  direction  of  the  growing  projection,  until  b}^  its  own  exertions, 
and  aided  by  the  vis  a  tergo,  it  has  finished  its  journey  through  the  capil- 
lar}'^ wall,  and  has  reached  the  para-vascular  lymph  or  connective-tissue 
spaces,  where  it  constitutes  the  most  important  element  of  the  inflam- 
matory exudation.  In  the  inflamed  capillaries  of  the  frog's  web,  under 
the  microscope,  this  process  of  emigration  can  be  readil}^  followed,  and 
leucoc3'tes  can  be  seen  in  the  same  field  in  various  stages  of  transit 
through  the  wall,  and  finall}'  liberated  in  the  para-vascular  spaces.  Fre- 
quently one  leucocyte  after  another  can  be  seen  passing  through  the 
same  place, — a  fact  which  points  stronglj'  to  the  existence  of  well-defined 
circumscribed  defects  in  the  capillary  wall.  As  the  escaped  leucocytes 
accumulate  outside  of  the  capillary  vessels,  some  of  them  can  be  seen  to 
change  their  location  b}^  the  same  forces  which  have  been  active  in  their 
passage  tlirough  the  vessel-wall, — amoeboid  movements  and  stream  of 
parenchyma  fluid. 

Diapedesis. — This  word  was  devised  by  Strieker  to  designate  the 
passage  of  colored  corpuscles  through  the  inflamed  vessel-wall.  If  there 
could  be  any  doubt  as  to  the  existence  of  minute  openings  in  the  inflamed 
capillary  wall  in  the  consideration  of  emigration  of  leucocytes,  this 
doubt  must  be  eff'ectuall}'  dispelled  when  the  passage  of  colored  corpuscles 
through  the  capillaiy  wall  can  be  demonstrated  under  the  microscope. 
Experimental  research  and  clinical  observation  have  shown  that  when 
the  inflammatory  action  is  very  intense  red  corpuscles  form  no  inconsid- 
erable part  of  the  inflammator}'  exudation.  As  the  colored  corpuscles 
possess  no  amoeboid  movements,  their  passage  through  the  capillary 
wall  must  be  an  entirely  passive  process  ;  the}'  are  extruded  through  pre- 
formed openings  or  through  an  exceedingly  soft  cement-substance  by  the 
intra-vascular  pressure.  It  is  possible  that  they  are  forced  tlirough  pas- 
sages made  by  the  emigration  corpuscles.  It  is  well  known  that  at 
first  only  leucoc^'tes  are  found  outside  of  the  capillary  vessels,  that  the 
colored  corpuscles  appear  later,  and  that,  while  leucocytes  also  pass 
through  the  smallest  veins,  the  colored  corpuscles  escape  only  through 
capillar}^  vessels  (Fig.  37,  D). 

Arnold  noticed  that  red  corpuscles  floating  in  the  capillary  stream, 
when  they  arrived  opposite  a  stomata,  were  drawn  toward  the  opening 
of  the  transudation  stream. 

Diapedesis  becomes  a  prominent  feature  where  the  inflammatory 
process  is  very  acute,  consequently  where  extensive  alteration  of  the 
vessel-walls  has  taken  place.  In  such  instances  the  colored  corpuscles 
are  so  numerous  in  the  exudation  as  to  impart  to  it  a  hsemorrhagic 


88 


PRINCIPLES   OF    SURGERY. 


appearance.  An  abundant  escape  of  colored  corpuscles  in  inflammation 
is  technicall}'  called  rhexis.  The  tliird  corpuscles  are  extruded  through 
the  inflamed  capillary  wall  in  the  same  passive  way  as  the  colored 
corpuscles. 

The  primary  inflammatory  exudation  consists  of  the  corpuscular 
elements  of  the  blood  which  escape  through  the  porous  capillary  wall, 
the  products  of  their  disintegration,  and  blood-plasma.  The  latter  will 
be  again  referred  to  under  the  head  of  Transudation.  The  presence  of 
the  solid  constituents  of  the  blood  differentiates  the  inflammatory  exuda- 
tion from  an  ordinary  hydropic  or  oedematous  swelling.     The  question 


Fig.  37.— Inflammation  of  Frog\s  Web  at  Stage  where  Capillary  Stream 
IS  Impeded  by  Commencing  Emigration.    (Landerer.) 

a,  small  artery ;  B,  small  vein  ;  C,  capillaries  ;  D,  red  corpuscles  which  have  escaped  from  capillary  by  diapedesis. 

rises.  What  becomes  of  the  corpuscular  elements  after  they  have  left  the 
general  circulation  ?  The  most  favorable  termination  of  the  inflamma- 
tor}^  process  consists  in  the  preservation  of  the  vitality  of  the  cellular 
elements  outside  of  the  blood-vessels  and  their  return  into  the  general 
circulation  by  a  process  which  is  called  immigration.  This  probably 
seldom,  if  ever,  takes  place  in  the  case  of  the  colored  and  third  cor- 
puscles, both  of  Avhich  possess  no  amoeboid  movements  and  undergo 
molecular  disintegration,  and  the  granular  detritus  is  removed  by  absorp- 
tion. The  leucocytes  which  have  retained  their  vitality  can  return  into 
the  circulation  either  by  re-entering  the  capillaries  which  they  have  left, 


SYMPTOMS   OF   INFLAMMATION.  89 

after  the  acute  S3"mptoms  have  subsided  and  the  capillaries  have  been 
cleared  of  the  mural  thrombi,  or  b}'  a  more  indirect  route  through  the 
lymphatic  vessels.  The  latter  route  is  probably  the  most  frequent.  If 
the  blood-corpuscles  contain  the  microbic  cause  of  the  inflammation  in 
sufl3cient  qnantitv  and  intensity  to  destroy  their  protoplasm,  they  fur- 
nish the  necessarj-  nutrient  medium  for  the  growth  and  development  of 
the  microbe  outside  of  the  vessel-wall,  thus  bringing  it  in  direct  contact 
with  the  para-vascular  tissues,  which  then  become  the  seat  of  infection. 
In  such  instances  the  cellular  elements  of  the  primary  inflammator}'  exu- 
dation are  dead  tissue,  and  act  or  are  disposed  of  as  such.  In  acute 
suppurative  inflammation  the  leucocytes  which  have  escaped  are  con- 
verted into  pus-corpuscles.  The  einigration  corpuscle  under  no  circum- 
stances assumes  a  tissue-producing  function.  When  inflammatory  proc- 
esses result  in  the  formation  of  new  tissue,  this  function  is  performed  by 
fixed  tissue-cells  which  have  been  stimulated  to  a  state  of  activity'  hy 
the  increased  nutritive  conditions  incident  to  some  form  of  inflamma- 
tion. The  albumen,  which  is  alwaj's  present  in  considerable  quantity  in 
every  inflammator}'  exudation,  furnishes  an  additional  nutrient  supply, 
and  thus  assists  the  process  of  cell  proliferation ;  this  is  especially  the 
case  with  the  globulins.  The  filtrate  which  percolates  through  the  in- 
flamed capillary  wall  contains  coagulable  substances,  which,  in  hydropic 
fluids,  are  less  abundant.  The  emigration  corpuscles,  which  disintegrate 
soon  after  they  have  left  the  capillar}'  vessels,  furnish  fibrin  ferment. 
Fibrin  production  in  the  tissues  is  suspended  as  soon  as  the  product  of 
emigration  has  become  copious.  The  third  corpuscles  furnish  another 
source  of  fibrin  production.  In  suppurative  inflammation  fibrin  forma- 
tion does  not  take  place.  Where  no  fibrin  forms  in  the  exudation,  the 
supposition  lies  near  that  the  fibrin-producers  are  taken  up  by  the  cells, 
or  that  the  fibrin  which  had  already  been  produced  is  liquefied  and 
assimilated  hy  them.  If  the  inflamed  vessels  are  surrounded  only  by 
a  few  leucocytes,  the  latter  are  destroyed  and  liberate  fibrin  ferment ; 
if  abundant,  they  are  more  resistant  and  destroy  albuminous  substances. 
AVeigert  asserted  that  cell  necrosis  resulted  in  the  formation  of  fibrin,  as 
the  dead  cells  furnish  the  fibrin  ferment.  That  fibrin  production  does 
not  always  attend  inflammation  can  onl}^  be  explained  b}'  the  supposition 
that  the  fibrin-producers  are  assimilated  as  soon  as  they  have  left  the 
blood-channels.  If  the  cells  which  furnish  the  fibrin  come  in  contact 
with  necrotic  tissue,  such  an  assimilation  is  prevented  and  fibrin  is 
formed.  Fi])rin  production,  however,  may  take  place  without  cell  necro- 
sis, as  is  the  case  upon  inflamed  serous  surfaces.  Its  occurrence  in  this 
particular  locality  can  onl}"  be  explained  by  the  absence  of  assimilation 
of  the  cells  which  yield  the  fibrin  ferment.     The  cellular  constituents 


90  PRINCIPLES   OF    SURGERY. 

and  fibrin  of  the  inflammatory  exndation  impart  to  it  one  of  its  charac- 
teristic clinical  features, — a  sense  of  firmness, — which  is  well  marked  in 
proi)ortion  to  the  predominance  of  these  over  the  fluid  portion. 

Inflammatopy  Transudation. — The  liquid  ])ortion  of  the  blood  which 
escapes  through  the  damaged  wall  of  inflamed  capillary  vessels  is  called 
inflammatory  transudation.  The  same  causes  which  are  necessary  to 
extrude  the  non-amreboid  corpuscular  elements  of  the  blood  constitute 
also  the  conditions  which  enable  a  part  of  the  blood-plasma  to  leave  the 
capillary  stream.  Increased  porosity  of  the  capillary  Mall  is  the  most 
important  of  them.  As  soon  as  the  capillar}^  wall  has  become  abnor- 
mally permeable  the  blood-pressure  forces  the  fluid  tlirough  the  minute 
pores  into  the  surrounding  connective  tissue,  or,  if  the  inflammation  is 
located  in  a  mucous  or  serous  membrane,  upon  the  surface.  In  deep- 
seated  inflammation  the  transuded  fluid  freely  percolates  through  the 
connective-tissue  spaces,  and  gives  rise  to  one  of  the  well-known  symp- 
toms of  inflammation, — the  inflammatory  oedema.  The  transudation  is 
always  more  widely  diff'used  than  the  exudation.  Recent  bacteriological 
researches  have  shown  that,  while  in  the  tissues,  at  the  seat  of  exuda- 
tion, the  presence  of  the  microbic  cause  of  the  inflammation  can  be 
readily  demonstrated  by  microscopical  examination  and  cultivation  ex- 
periments, the  cedema  fluid  some  distance  from  them  was  found  free  from 
micro-organisms.  The  escape  of  blood-plasma  in  inflammation  is  a  proc- 
ess which  resembles  percolation  through  a  porous  membrane.  As  the 
blood-plasma  contains  fibrinogen  and  fibrino-plastic  material,  its  presence 
in  the  tissues  or  upon  inflamed  serous  or  mucous  membranes  is  impor- 
tant in  the  production  of  fibrin.  In  some  instances  the  inflammatory 
product  is  greatly  changed  by  the  presence  of  a  copious  transudation, 
and  the  inflamed  part  then  presents  more  the  appearance  of  oedema  than 
inflammation.  This  is  well  shown  by  the  two  clinical  varieties  of  anthrax. 
The  expression  serous  inflammation  is  used  to  indicate  the  predominance 
of  transudation  over  exudation  in  some  forms  of  inflammation.  The 
liquid  transudate  predominates  over  the  exudate  in  some  forms  of  sup- 
purative inflammation  (purulent  oedema  of  Pirogoflf),  also  when  the 
circulation  is  feeble,  as  in  the  aged  and  in  anaemic  individuals.  The 
addition  of  mucus  alters  the  character  of  an  exudation  or  a  transudation, 
as  may  be  seen  when  a  mucous  membrane  is  the  seat  of  inflammation. 
Serous  transudation  often  precedes  mucous  exudation,  as  in  cases  of 
acute  catarrlial  inflammation  of  the  nasal  passages.  After  the  acute 
symptoms  of  inflammation  have  subsided  and  the  capillary  circulation 
has  been  restored,  the  transuded  fluid  is  absorbed,  and  with  its  absorp- 
tion the  inflammatory  oedema  disappears.  In  suppurative  inflammation 
the  transudation  becomes  the  pus-serum. 


SYMPTOMS   OF    INFLAMMATION.  91 

(d)  Heat. — Increase  of  temperature  of  the  inflamed  part  is  the  result 
of  increased  afflux  of  blood  and  the  accompanying  augmentation  of 
physiological  processes.  Cohnheim  showed  experimentally  that  inflam- 
mation, without  an  increased  blood-supply,  does  not  give  rise  to  an 
increase  of  temperature.  Jolm  Hunter  was  already  aware  that  the 
temperature  at  the  seat  of  inflammation  is  never  in  excess  of  the  tem- 
perature of  the  blood.  Heat  is  both  a  subjective  and  objective  s^-mptom. 
In  acute  inflammation  of  the  skin,  or  a  mucous  membrane,  the  patient 
often  complains  of  a  distressing  burning  or  scalding  sensation,  which  is 
often  effectually  relieved  by  cold  applications.  The  surface  thermometer 
is  sometimes  an  important  instrument  in  setting  a  differential  diagnosis 
between  a  deep-seated  chronic  inflammation  and  a  malignant  tumor. 
Diminution  of  temperature  may  indicate  either  a  favorable  change  or 
complete  arrest  of  circulation  in  the  inflamed  part,  in  the  first  instance 
showing  that  resolution  is  in  progress,  in  the  latter  commencing  the 
speedy  occurrence  of  gangrene. 

(e)  Disturbance  of  Function. — As  inflammation,  wherever  it  occurs, 
consists  essentially  of  increased  nutritive  changes  in  the  tissues,  result- 
ing in  consequence  of  a  more  abundant  blood-suppl}'  and  an  exaggerated 
vegetative  capacity  of  the  cells,  it  ma}^  lead  to  at  least  a  temporary  in- 
crease of  function.  This  is  always  the  case  in  inflammation  of  mucous 
membranes,  where,  as  one  of  the  prominent  clinical  features,  we  observe 
an  increased  secretion  of  mucus  usually  preceded  and  accompanied  by 
a  more  or  less  profuse  transudation.  Parenchjanatous  inflammation  in 
glands  usually  produces  sudden  diminution  and  often  complete  suppres- 
sion of  secretion.  Acute  suppurative  osteomyelitis  is  attended  by  almost 
complete  suspension  of  all  the  functions  of  the  aflfected  limb.  Myositis 
arrests  the  contractility  of  the  muscles  aff"ected.  The  pain  caused  by 
an  inflammation  may  interfere  with  the  functions  of  adjacent  organs,  as 
may  be  seen  in  the  fixed  chest-wall  in  cases  of  acute  pleuritis,  and  in  fixa- 
tion of  the  abdominal  walls,  with  diminished  or  suspended  respiratory 
movements  of  the  diaphragm,  in  cases  of  peritonitis.  Tlie  accumulation 
of  inflammatory  products  may  prove  a  serious  obstacle  to  important 
functions,  and  often  constitutes  a  direct  cause  of  death,  as  in  cases  of 
intra-cranial  inflammation,  where  death  is  more  frequently  caused  by  com- 
pression of  the  brain  than  destruction  of  the  contents  of  the  cranial  cavity ; 
and  the  accumulation  of  serum  or  pus  in  the  pleural  cavity  or  pericardium, 
where  a  fatal  termination  can  often  be  traced  to  mechanical  causes  from 
the  presence  of  a  copious  eflTusion.  Diminution  of  function  often  aflTords 
the  earliest  indication  of  the  existence  of  a  deep-seated  chronic  inflam- 
mation, as  is  evident  from  the  slight  limp  which  ushers  in  a  coxitis  or 
the  imperfect  flexion  and  extension  in  chronic  inflammation  of  joints 
other  than  the  hip-joint. 


CHAPTER  IV. 

Inflammation  {continued). 

MODIFICATION    OF   INFLAMMATION    BY    THE    ANATOMICAL    STRUCTURE 
AND    LOCATION    OF    THE    INFLAMED    TISSUE. 

The  clinical  course  and  pathological  conditions  of  inflammatory 
processes  are  materially  modified  not  only  by  the  primarj^  cause,  but 
also  b}^  the  anatomical  structure  and  location  of  the  inflamed  tissues. 
Inflammation  of  serous  or  mucous  surfaces  has  a  tendenc}'  to  spread  in 
a  peripheral  direction,  and,  as  a  rule,  remains  superficial,  and  the  exuda- 
tion and  transudation  are  poured  out  in  the  direction  offering  the  least 
resistance;  that  is,  upon  the  free  surface.  In  tissues  that  are  dense  and 
un^'ielding  the  swelling,  for  physical  reasons,  is  limited,  and  the  inflam- 
mator}^  products  givQ  rise  to  tension,  which  may  arrest  the  circulation 
completely  and  cause  necrosis,  as  is  the  case  in  acute  suppurative  osteo- 
myelitis. When  the  area  of  inflammation  is  supplied  with  an  abundance 
of  connective  tissue  the  swelling  often  attains  enormous  dimensions  in 
a  short  time,  as  may  be  seen  in  ever}-  case  of  phlegmonous  inflammation 
of  the  deep-seated  connective  tissue  of  the  extremities,  neck,  chest,  and 
abdomen.  Acute  inflammation  of  organs  that  are  exceedingly  vascular 
gives  rise  to  an  early  and  abundant  exudation,  as  can  be  demonstrated  in 
every  case  of  croupous  pneumonia  and  acute  nephritis.  Inflammation 
of  non-vascular  tissue  is  accompanied  by  the  formation  of  new  blood- 
vessels, which  grow  in  the  direction  of  the  seat  of  inflammation  from  the 
nearest  vascular  district.  Some  tissues  are  more  disposed  to  inflamma- 
tion than  others  ;  thus,  the  connective  tissue  is  more  frequently  the  seat 
of  acute  inflammation  than  muscles,  and  the  medullar}'  tissue  than  the 
bone-substance  proper,  and  most  causes  which  give  rise  to  chronic 
inflammation  are  known  to  select  certain  organs  and  tissues  in  preference 
to  others. 

PARENCHYMATOUS   INFLAMMATION. 

In  the  stud}-  of  the  cardinal  symptoms  of  inflammation  special 
attention  was  given  to  the  part  taken  in  the  inflammatory  process  b}'^  the 
capillary  vessels  and  the  blood-corpuscles.  Alteration  of  the  capillary- 
wall  was  alluded  to  as  the  most  important  pathological  condition,  as 

(93) 


94  PRINCIPLES   OF    SURGERY. 

upon  it  depends  the  emigration  of  the  corpuscuhir  elements  of  the  blood 
and  the  occurrence  of  tiie  inflammatory  transudation,  which  together 
constitute  the  primary  inllammatory  swelling.  Incidentally  it  was  stated 
that  as  soon  as  the  cause  wliich  gave  rise  to  the  inflammation  is  brought 
in  direct  contact  with  the  fixed  tissue-cells,  these  take  part  in  the  in- 
flammatory process  and  contribute  their  share  to  the  inflammatory  exu- 
dation. Inflammation  is  said  t®  be  parenchymatous  when  the  parenchyma 
of  an  organ  is  the  primary  seat  of  inflammatory  changes,  as  when  the 
secreting  structures  of  a  gland  are  implicated  from  the  beginning.  In 
all  such  instances  the  blood-vessels  which  furnish  the  vascular  supply 
have  undergone  the  characteristic  changes  which  have  been  described, 
and  with  few  exceptions  the  microbes  have  been  conveyed  to  tlie 
parenchyma  through  them.  The  cloudy  swelling  of  parenchyma  cells  is 
either  an  evidence  of  the  existence  of  degenerative  changes,  or  it  denotes 
the  beginning  of  coagulation  necrosis  from  the  specific  effect  of  patho- 
genic microbes  upon  their  protoplasm.  A  cloudy  appearance  of  cells  is 
one  of  the  first  manifestations  of  tlie  presence  of  a  parenchymatous  in- 
flammation. Lesion  of  connective  tissue  or  parenchyma  cells  is  next  to 
alteration  of  capillary  wall,  and  emigration  of  blood-corpuscles  the  most 
important  pathological  condition  of  inflammation,  and,  as  far  as  the 
ultimate  result  is  concerned,  the  most  important,  as  extensive  destruction 
of  parenchyma  cells  will  result  in  suspension  of  function,  and  death  of 
the  organ  affected  is  one  of  vital  importance.  As  soon  as  the  fixed  tissue- 
cells  outside  of  the  vessel-wall  have  become  implicated  their  physiological 
resistance  is  diminished, — a  condition  which  cannot  fail  in  aggravating  the 
existing  vascular  disturbances.  Landerer  maintains  that  the  normal 
elasticity  of  the  tissues  surrounding  the  capillary  vessels  is  an  essential 
factor  in  preserving  the  equilibrium  between  the  intra-A'ascular  pressure 
and  the  surrounding  tissues  in  a  normal  condition  of  the  circulation. 
This  mechanical  theory  of  inflammation  is  founded  upon  the  supposition 
that  this  normal  elasticit3^  of  the  para-vascular  tissues  is  diminished  by 
the  causes  which  give  rise  to  inflammation,  and  that  when  this  has 
occurred  the  capillary  walls  have  lost  their  outer  support,  in  consequence 
of  which  they  become  dilated,  and  hyperemia,  slowing  of  blood-current, 
emigration,  and  transudation  follow  as  the  result  of  purely  mechanical 
causes.  Ingenious  as  this  theoi-y  may  appear,  it  cannot  explain  the 
complicated  processes  which  characterize  inflammation.  The  train  of 
pathological  conditions  which  attend  inflammation  must  be  regarded  as 
effects  of  a  common  microbic  cause  upon  the  capillary  wall,  their  con- 
tents, and  the  fixed  tissue-cells  outside  of  the  capillary  vessels.  In 
parench3unatous  inflammation  the  cause  has  reached  the  parench,yma 
cells,  either  directly,  as  when  microbes  are  brought  in  contact  with  a 


INTERSTITIAL    INFLAMMATIOK.  95 

mucous  surface,  become  attached  to  and  penetrate  the  parenchyma  cells, 
multiply  in  their  interior,  and,  later,  reach  the  connective  tissue  and 
blood-vessels,  or,  what  is  more  common,  the  microbes  reach  the  paren- 
chyma through  the  circulation.  In  both  instances  the  capillary  vessels 
and  the  connective  tissues  between  them  and  the  parenchj'ma  cells  take 
an  active  part  in  the  inflammatory  process.  The  microbes  may  be 
present  in  such  great  number  or  may  possess  such  intensel}^  virulent 
properties  as  to  destroy  the  parenchyma  cells,  as  is  the  case  in  diphtheritic 
inflammation  of  mucous  membranes.  When  less  intense  in  their  action 
the  parenchyma  cells  proliferate,  and  the  embryonal  cells,  being  less  re- 
sistant, succumb  later,  as  when  suppuration  occurs  in  the  parench}  ma 
of  an  organ,  or  they  remain  indefinitely  in  their  embrj^onal  state,  as  can 
be  readil}^  verified  by  examining  the  difterent  forms  of  chronic  inflam- 
matory swellings, — the  so-called  granulomata. 

INTERSTITIAL    INFLAMMATION. 

In  this  form  of  inflammation  the  connective  tissue  is  the  seat  of  cell 
emigration  and  tissue  proliferation.  Many  of  the  microbes  select  the 
connective-tissue  spaces ;  they  locate  and  multiply  here,  and  the  inflam- 
mator}^  product  is  composed  almost  exclusively  of  emigration  corpuscles 
and  embr3'onal  connective-tissue  cells.  Tubercle  and  gummata  present 
such  a  histological  structure.  Phlegmonous  inflammation  represents  the 
acute  form  of  connective-tissue  inflammation.  If  the  connective  tissue 
of  an  organ  become  the  seat  of  an  inflammator}^  hyperplasia  the  paren- 
chyma suftel's,  either  in  consequence  of  pressure  or,  later,  from  cicatricial 
contraction  and  the  inevitable  diminution  of  blood-suppl}^  incident  to 
this  condition.  Parenchymatous  inflammation  of  an  organ  is  preceded 
or  followed  b}^  interstitial  inflammation,  and  a  primarily  interstitial  in- 
flammation sooner  or  later  involves  the  surrounding  tissue  b}'  direct 
extension  of  the  inflammatory  process,  or  indirectly  the  mechanical 
causes ;  hence,  as  a  rule,  it  is  anatomically  and  even  etiologicalh-  not 
always  possible  to  differentiate  between  these  two  forms  of  inflammation, 
nor  is  such  a  distinction  of  much  practical  importance. 

HEMORRHAGIC    INFLAMMATION. 

A  few  colored  corpuscles  escape  through  the  capillary  wall  in  almost 
every  case  of  acute  inflammation,  but  their  presence  in  the  exudation 
can  onl}^  be  determined  b}^  the  use  of  the  microscope.  When  they  are 
present  in  sufficient  number  to  impart  to  the  exudation  a  bloody  tinge, 
we  speak  of  a  hsemorrhagic  exudation  or  transudation.  A  hsemorrhagic 
transudation  into  the  pleural,  pericardial,  or  peritoneal  cavit}'  usually 
indicates   the   existence  of  a  tubercular   or   malignant   disease  of  the 


96  PRINCIPLES   OF   SURGERY. 

respective  serous  membranes.  In  cases  of  acute  inflammation  with  hsem- 
orrliagic  exudation,  the  quantity  of  the  effused  blood  will  be  a  sign  by 
which  we  can  at  least  approximately  estimate  the  extent  of  alteration  of 
the  capillary  wall.  Rhexis  can  only  take  place  when  the  capillary  wall 
at  some  point  has  been  completel}'  broken  down  and  an  opening  of  con- 
siderable size  has  formed  through  which  a  small  stream  from  the  axial 
current  can  escape.  Aside  of  the  nature  and  intensity  of  the  primary 
cause  of  the  inflammation,  ha?morrhagic  inflammation  is  more  likely  to  be 
met  with  in  persons  debilitated  from  other  diseases,  in  the  aged,  and  in 
patients  suflering  from  diseases  which  obstruct  the  circulation,  such  as 
valvular  disease  of  the  heart,  cirrliosis  of  the  liver,  emphysema  of  the 
lungs,  and  chronic  atlections  of  tlie  kidney.  The  presence  of  blood  in  a 
transudation  or  exudation  is  always  a  grave  sign,  and  as  such  should 
always  be  taken  into  careful  consideration  in  rendering  a  prognosis. 

SUPPURATIVE    INFLAMMATION. 

In  suppurative  inflammation  at  least  a  part  of  the  exudation  is 
transformed  into  pus.  Transformation  of  the  cellular  portion  of  the 
exudation,  the  leucocytes  and  embr3'onal  cells,  into  pus-corpuscles  is  due 
to  the  destructive  effect  upon  their  i)rotoplasm  of  the  pus-microbes  and 
their  ptomaines,  while  the  transudate  becomes  the  pus-serum.  Suppu- 
rative inflammation  occurs  either  as  tlie  result  of  a  primary  or  secondary 
infection  with  pus-microbes.  In  primary  infection  with  pus-microbes 
the  leucoc^'tes  most  remote  from  the  blood-vessels,  and  which  have  been 
exposed  longest  to  the  specific  action  of  the  pus-microbes  and  their 
ptomaines,  are  converted  first  into  pus-corpuscles,  while  the  fixed  tissue- 
cells  are  first  transformed  into  embryonal  cells  before  the  same  cause,  by 
destruction  of  their  protoplasm,  changes  them  into  similar  structures.  In 
suppurative  inflammation  due  to  secondary  infection,  the  pus-microbes 
act  upon  embr3'onal  cells  which  owe  their  origin  to  an  antecedent  infec- 
tion witli  another  microbe  of  milder  patliogenic  qualities,  as  can  be  seen 
when  tubercular  granulations  or  a  gumma  undergo  suppuration.  Sup- 
purative inflammation,  in  all  of  its  aspects,  will  be  fully  considered  in  the 
chapter  on  Suppuration. 

INFLAMMATION  OF  SEROUS  MEMBRANES. 
Inflammation  of  the  serous  membranes  has  been  called  exudative, 
adhesive,  suppurative,  or  serous,  according  to  the  character  of  the  in- 
flammatorj?^  product.  In  most  inflammatory  affections  of  the  serous 
membranes  the  surface  becomes  covered  with  a  copious  exudation,  which 
is  composed  of  leucocytes,  fibrin,  and  the  products  of  tissue  proliferation 
of  the  endothelial  and  connective-tissue  cell.     Tlie  leucocytes  and  third 


INFLAMMATIOJf    OF   SEROUS   MEMBRANES. 


97 


corpuscles  are  rapidl}-  destroyed  as  tliey  reach  the  surface,  and  the  fibrin 
ferment  and  fibrino-plastic  material  "which  are  liberated  form,  on  com- 
bining with  the  fibrinogen  of  the  blood-plasma,  fibrin.  Tlie  inflamed 
membrane  is  often  covered  by  a  tliick  la3'er  of  fibrin,  which  is  firmly 
adherent  to  the  surface  by  means  of  new  blood-vessels  and  granulation 
tissue  w'hich  have  grown  into  it.     The  endothelial  cells  take  an  active 


Fig.  38.— Germikating  Endothelitim,  OMENTtJM  of  Yotjxg  Dog.    Acute  Peritonitis. 
Silver-staining,  X  3.50.    (Hamilton.) 

A,  natural  endothelium  covering  wall  of  a  mesh :   B,  D,  endothelial  cells  beginning  to  germinate ;  C,  a  chain 
of  germinating  cells  extending  across  a  fenestra;  E,  mass  of  germinating  endothelial  cells. 

part  in  the  inflammation,  and  in  case  the  new  product  from  this  source 
is  converted  into  connective  tissue  a  permanent  adhesion  forms.  In 
some  instances  the  endothelial  cells  are  destroyed  and  desquamation 
takes  place,  which  leaves  the  subjacent  connective  tissue  exposed.  In 
such  cases  the  superficial  dilated  capillaries  have  lost  an  important  sup- 
port, and  transudation  takes  place  freely.     D.  J.  Hamilton  has  studied 


98 


PRINCIPLES   OF    SURGERY. 


the  histological  changes  which  occur  in  periostitis  by  producing  this 
disease  artificially  in  young  dogs.  Besides  desquamation,  he  lias  seen 
the  endotlielial  cells  multiply  by  division  of  the  nucleus. 

The  new  cells  resemble  the  ordinary  granulation  or  embryonal  cells. 
The  connective  tissue  l)etween  tlie  endothelial  lininof  and  the  blood-vessels 


4,m 


c 


i^§^,i^^^^^,^^^/c/r)j 


7/  /  IX — -  -•    -' 


Fig.  39.— Omentum  of  Young  Dog,  Experimentally  Inflamed.    X  450.    (Hamilton.) 

A,  pyriform  cell,  probably  of  enflothelial  origin,  sprouting  from  wall  of  a  fenestra  (S)  of  the  membrane; 
C,  capillary,  Biirrounded  by  extravasated  leucocytes  ;  V,  small  vein,  in  similar  condition. 

undergoes  tissue  proliferation,  and  the  new  cells  reach  the  surface  and 
mingle  with  those  derived  from  the  endotlielial  lining,  so  that  the  inflamed 
surface  becomes  covered  with  a  layer  of  granulation  tissue.  The  granu- 
lations, accompanied  by  dilated  or  new  blood-vessels,  penetrate  into  the 
fibrinous  exudation,  which  is  removed  in  the  same  manner  as  a  thrombus 


INFLAMMATION    OF    SEROUS    MEMBRANES. 


99 


in  a  blood-vessel  undergoing  obliteration.  Permanent  adhesions  and 
obliteration  of  serous  cavities  are  atfected  by  the  granulation  tissue, 
which  removes  the  inflammatory  exudation  and  establishes  an  organic 
union  between  opposing  inflamed  membranes.  If  the  fixed  tissue-cells 
do  not  participate  actively  in  the  juflanimatory  process,  the  exudation 
becomes  absorbed  in  the  course  of  time,  and  the  endothelial  lining  is 
repaired;  thus  the  temporar3'' adhesions  are  removed,  and  the  normal 


Fig.  40.— Acute  Pleurisy,    x  300.    (Hamilton.) 

A,  A,  net-work  of  fibrin;  B,  an  effuseil  leucocyte;  C,  laminfe  of  fibrin  lying  adjacent  to  the 
pleura  (F) ;  D,  small  round  cells  eft'used  into  the  pleura ;  E,  distended  blood-vessel  of  the  superficial 
layer  of  pleura. 

relations  existing  between  the  serous  membrane  and  inelosea  viscera  are 
restored.  The  blending  of  the  corpuscular  elements  of  the  inflammatory 
exudation  of  a  serous  membrane  with  the  product  of  tissue  proliferation 
of  the  endothelial  cells  is  well  shown  in  Fig.  39. 

The  pathological  anatomy  of  acute  inflammation  of  a  serous  mem- 
brane at  an  early  stage  is  well  represented  in  Fig.  40. 

The  scarcitj'  of  leucocytes  in  the  fibrin  in  the  specimen  represented 
by  this  illustration  was  undoubtedly  due  to  their  rapid  destruction  as 


100  PRINCIPLES   OF    SURGERY. 

soon  as  they  reached  the  surface,  whicli  resulted  in  the  formation  of  a 
copious  deposit  of  fibrin.  The  round  cells  in  the  subpleural  connective 
tissue  are  elFused  leucoc3'tes.  Sufficient  time  does  not  seem  to  have 
elapsed  for  any  marked  clianges  to  have  occurred  in  the  fixed  tissue-cells. 
In  suppurative  inflammation  of  a  serous  membrane,  if  life  is  sufficiently 
prolonged,  the  leucocytes  and  embryonal  cells  are  transformed  into  pus- 
corpuscles,  and  in  this  manner  empyema,  pyocardium,  and  purulent 
peritonitis  are  produced.  The  introduction  of  pus-microbes  in  sufficient 
quantity  into  the  abdominal  cavity,  the  power  of  absorption  of  which 
has  been  reduced  by  an  antecedent  affection  or  an  accompanying  trauma, 
will  produce  such  a  rapidly  fatal  peritonitis  that  tiie  pei-itoneum,  on  post- 
mortem examination,  will  show  little,  if  any,  macroscopical  lesions. 
Death  in  such  cases  results  from  acute  septic  infection.  When  life  is  pro- 
longed for  several  days,  the  post-mortem  reveals  all  the  evidences  of  a 
fibrino-plastic  peritonitis ;  that  is,  numerous  adhesions  between  the 
intestines  and  the  parietal  peritoneum  and  among  the  intestinal  loops. 
In  purulent  peritonitis  the  exudation  often  breaks  down  as  the  leuco- 
cytes contained  in  it  are  converted  into  pus-corpuscles.  Tubercular 
peritonitis  is  usually  attended  by  a  copious  exudation,  which  limits  the 
process  and  encapsulates  the  serous  transudation.  If,  in  an  inflamma- 
tion of  a  serous  membrane,  the  transudation  predominates  over  the 
exudation,  the  character  of  the  process  is  indicated  clinically  b}^  a 
subacute  or  chronic  course  and  the  absence  of  severe  symptoms.  H3'dro- 
thorax  often  develops  insidiously,  and  perhaps  the  first  subjective 
symptom  is  difficulty  of  breathing.  Tubercular  peritonitis  with  copious 
circumscribed  effusion  has  been  frequently  mistaken  for  ovarian  cyst, 
not  only  because  the  swelling  closel}^  resembles  a  unilocular  ovarian 
cyst,  but  also  from  the  absence  of  au}^  of  the  usual  local  symptoms  which 
attend  the  usual  forms  of  fibrino-plastic  peritonitis.  It  appears  that  the 
causes  which  give  rise  to  the  form  of  inflammation  of  serous  membranes 
do  not  act  with  sufficient  intensity  on  the  capillaiy  wall  and  the  para-vas- 
cular tissues  to  provoke  a  copious  exudation  and  active  tissue  prolifera- 
tion, but  create  conditions  which  permit  a  copious  transudation  to  take 
place.  It  has  been  recently  a  much-discussed  question  "whether  or  not 
all  cases  of  serous  effusion  into  the  chest  are  of  tubercular  origin.  The 
fact  remains  that  many  cases  of  subacute  and  chronic  pleurisy  die  subse- 
quently from  tuberculosis,  and  the  natural  conclusion  would  be  that  the 
disease  was  primarily  caused  by  a  localized  tubercular  focus,  which,  at 
the  time,  could  not  be  detected.  It  is  evident  that  the  causes  which 
produce  serous  transudation  do  so  not  only  bj?^  producing  changes  in  the 
capillary  wall  which  permit  free  transudation,  but  also  by  bringing  about 
alterations  which  diminish  or  completely  suspend  the  power  of  absorp- 


INFLAMMATION    OF    MUCOUS   MEMBRANES.  101 

tion  ;  hence,  not  onl^'  the  occurrence  of  transudation,  but  accumulation 
of  the  liquid  effused.  The  presence  of  blood  in  the  transudation  is 
usually  an  indication  of  the  presence  of  tuberculosis,  carcinoma,  or 
sarcoma. 

INFLAMMATION    OF    MUCOUS    MEMBRANES. 

Inflammation  of  a  mucous  membrane  represents  another  variet}'  of 
surface  inflammation  which  is  greatly  modified  by  the  anatomical 
character  of  the  tissue  the  seat  of  the  inflammatorj''  process.  We  have 
seen  that  inflammation  of  serous  membranes  pi'esents  as  its  most  charac- 
teristic pathological  feature  a  plastic  exudation  on  its  surface,  composed 
of  the  exuded  blood-corpuscles  and  the  products  of  their  disintegration, 
which  are  firmly  attached  to  the  endothelial  lining,  which  in  part  has 
been  destroj'ed  and  detached  by  desquamation,  while  the  cells  which 
have  retained  their  vitality  proliferate  new  tissue,  which  mingles  with 
and  ultimatel}^  removes  the  exudation.  The  epithelial  cells  which  line 
mucous  membranes  when  in  a  state  of  inflammation  are  stimulated  to 
increased  activity,  and  consequently  secrete  an  increased  quantit}^  of 
mucus,  which  is  the  characteristic  pathological  and  clinical  feature  of 

I.  CATARRHAL  INFLAMMATION. 
Inflammation  of  a  mucous  membrane  is  called  catarrhal  as  long  as 
the  product  consists  of  an  increased  secretion  of  mucus.  If  a  part  of 
the  mucous  lining  is  destroyed  and  the  discharge  becomes  a  mixture  of 
pus  and  mucus,  it  is  no  longer  proper  to  call  it  a  catarrhal  inflammation, 
as  the  pus-microbes  have  wrought  changes  that  bring  the  process  within 
the  legitimate  sphere  of  suppurative  inflammation.  Catarrhal  inflamma- 
tion produces  a  thickening  of  the  mucous  membrane  bj'  infiltration  of 
the  submucous  tissue,  which,  if  copious,  may  subsequently  give  rise  to 
cicatricial  contraction,  and,  if  the  inflammation  is  located  in  a  tubular 
organ,  to  the  formation  of  strictures.  According  to  Yirchow,  a  catarrhal 
inflammation  may  lead  to  the  formation  of  superficial  ulcers, — the  so- 
called  catarrhal  ulcers. 

II.  SUPPURATIVE  INFLAMMATION. 
In  this  form  of  inflammation  of  a  mucous  membrane,  the  leucocytes 
which  are  extruded  upon  its  surface,  as  well  as  the  embr^-onal  cells,  are 
destro^-ed  by  the  pus-microbes  and  are  converted  into  pus-corpuscles, 
which,  when  mixed  with  the  mucus  secreted  by  the  cells  which  have 
x-etained  their  physiological  function,  form  the  muco-purulent  discharge. 
Most  of  the  ulcers  which  form  i\\)on  mucous  surfaces  result  from  circum- 
scribed necrosis  or  suppurative  inflammation,  A  catarrhal  inflammation 
very  frequently  precedes  the  suppurative  form,  and  a  circumscribed  sup- 


102  PRINCIPLES    OF    SURGERY. 

purating  area  is  usually'  surrounded  by  a  zone  of  catarrhal  inflammation. 
Cicatricial  obliteration  of  a  tubular  organ  can  only  take  place  after  ex- 
tensive defects  of  its  mucous  lining  from  necrotic,  ulcerative,  or  trau- 
matic causes.  Limited  defects  are  repaired  by  regeneration  of  the  epi- 
thelial cells,  either  from  the  margins  of  the  defect  or  from  remnants  of 
glands.  The  most  frequent  causes  of  ulceration  in  the  intestinal  canal 
are  dysentery,  typhoid  fever,  and  tuberculosis.  Ulcers  which  result  from 
the  sudden  obliteration  of  a  small  blood-vessel  by  thrombosis  or  embolism 
are  met  with  after  extensive  burns  in  the  upper  portion  of  the  small  in- 
testine and  in  the  stomach  in  chlorotic  females.  A  strange  form  of 
perforative  enteritis  has  recently  been  described  by  Mikulicz.  A  similar 
case  was  operated  on  in  the  Zurich  Klinik,  and  a  careful  description  of 
the  pathological  conditions  found  at  the  necropsy  has  been  given  by 
Klebs.  He  found  multiple  perforations  in  a  circumscribed  portion  of 
the  jejunum,  and  onl}^  a  few  of  them  had  been  found  and  closed  by  the 
surgeon  who  performed  the  operation.  The  perforations  on  the  peri- 
toneal side  were  covered  by  a  plastic  exudation.  The  lumen  of  the 
intestine  corresponding  to  the  affected  portion  was  considerably  enlarged. 
Mucous  membrane  not  much  changed  in  appearance,  but,  on  close  inspec- 
tion, a  number  of  small  defects,  partly  hidden  under  the  folds,  were  de- 
tected, and  were  found  to  correspond  with  the  covered  defects  on  the 
outer  surface.  On  microscopical  examination,  it  was  found  that  the  villi 
and  mucous  membrane  were  softened  and  denuded  of  the  epithelial  lining 
and  infiltrated  with  cells  over  a  considerable  distance  beyond  the  per- 
forations. The  most  marked  changes  were  found  in  the  submucous  tissue, 
which  was  also  much  softened,  and  the  scanty  intercellular  substance 
was  found  traversed  by  wide  spaces  in  which  Avere  found  numerous  large 
cells  with  large  oval  nuclei.  Besides  these  enlarged  parenchyma  cells, 
and  in  their  vicinity,  leucocytes  which  had  undergone  fragmentation 
were  found.  As  the  capillary  vessels  were  much  dilated  and  in  a  con- 
dition of  inflammation,  Klebs  looks  upon  the  process  as  a  hyperplastic 
parenchymatous  enteritis.  As  the  leucocytes  found  in  the  tissues  pre- 
sented all  the  evidences  of  fragmentation,  there  can  be  but  little  doubt 
that  this  rare  form  of  enteritis  presents  only  another  variety  of  sup- 
purative inflammation  of  the  mucous  membrane  of  the  intestine. 

III.  CROUPOUS  INFLAMMATION. 
When  inflammation  of  a  mucous  membrane  is  attended  by  the 
formation  of  a  fibrinous  exudation  or  false  membrane  upon  its  surface, 
it  is  called  croupous.  The  formation  of  a  fibrinous  exudation  upon  a 
serous  surface,  we  have  found,  is  always  associated  with  a  more  or  less 
extensive  destruction  and  desquamation  of  endothelial  cells,  and  a  simi- 


INFLAMMATION    OF   NON-VASCULAR   TISSUE.  103 

lar  superficial  change  takes  place  in  croupous  inflammation.  Weigert 
states  that  unless  the  epithelial  surface  of  a  mucous  membrane  be 
broken  the  inflammatory  exudation  from  it  will  not  coagulate.  As 
croupous  inflammation  of  a  mucous  membrane  is  probably  always  pro- 
duced b}^  direct  infection,  it  is  probable  tliat  the  micro-organisms  destroj' 
some  of  the  epithelial  cells,  and  as  the  inflammatorj^  process  penetrates 
deeper  into  the  tissue,  the  exudation  and  transudation  coming  in  contact 
with  dead  tissue  on  the  surface,  fibrin  is  deposited,  and,  becoming  entan- 
gled with  the  cellular  debris,  it  becomes  adherent  to  the  partiall^'-abraded 
and  uneven  surface.  The  fibrin  is  arranged  in  layers  in  the  form  of  a 
coarse  net-work,  in  the  meshes  of  which  is  a  finer  reticulum  of  the  same, 
with  leucocytes  and  embryonal  cells  thrown  off  from  the  surface.  Some 
membranes  contain  numerous  leucocytes,  while  in  others  they  are  de- 
stroyed in  the  process  of  coagulation.  Separation  of  a  false  membrane 
takes  place  either  by  the  mucus  secreted  by  intact  cells  underneath  it,  or 
if  the  mucous  lining  has  been  completely  destroyed  by  suppuration  and 
granulation.  It  has  been  claimed  that,  pathologically,  a  croupous  mem- 
brane differs  from  a  diphtlieritic  exudation  in  that,  in  the  former,  the 
lining  of  the  mucous  membrane  is  found  intact  after  stripping  it  off, 
while  in  a  diphtheritic  inflammation  there  is  always  found  a  loss  of  sur- 
ft^'^e  substance  after  removing  the  membrane.  Upon  this  more  apparent 
than  real  anatomical  diflerence  the  discussion  on  the  non-identity  of 
croupous  and  diphtheritic  inflammation  rests.  As  superficial  coagula- 
tion necrosis  is  present  in  all  cases  of  croupous  inflammation,  and  if  this 
process  is  etiologically  difl!erent  from  diphtheritic  inflammation,  the 
pathological  conditions  are  different  only  in  degree  and  not  in  kind. 
False  membranes,  wherever  they  may  form  upon  a  mucous  or  serous  sur- 
face, serve  as  nutrient  media  for  micro-organisms,  and  the  underlying 
surface  is  subjected  to  the  risks  of  recurring  infection  from  them  as  long 
as  they  remain. 

INFLAMMATION    OF    NON-VASCULAR   TISSUE. 

The  importance  of  blood-vessels  in  inflammation  can  be  best  shown 
b}'^  a  study  of  the  pathological  conditions  in  inflammation  of  non-vascular 
tissue.  The  part  taken  b}^  the  blood-vessels  and  the  fixed  tissue-cells  in 
the  inflammatory  process  can  be  most  satisfactorily  demonstrated  in 
non-vascular  organs. 

Cornea. — Colmheim  first  demonstrated  emigration  of  the  colorless 
blood-corpuscles  in  artificially-produced  keratitis.  He  cauterized  the 
cornea  in  animals,  and  then  observed  cell  infiltration  from  its  margins  at 
a  point  corresponding  to  the  nearest  vascular  supply.  For  the  {)urpose 
of  showing  that  the  cells  were  not  products  of  the  fixed  tissue-cells  he 


104  PRINCIPLES   OF   SURGERY. 

injected,  a  few  days  before  the  cauterization,  finely-divided  cinnabar  into 
the  circulation,  and  found  that  the  leucocytes,  as  they  escaped  from  the 
capillary  vessels,  contained  granules  of  the  pigment  which  he  had  in- 
jected. The  leucocytes  were  seen  to  wander  through  the  vascular  spaces 
of  the  cornea  toward  the  seat  of  cauterization.  As  he  could  observe  no 
changes  in  tlie  fixed  corneal  corpuscles  at  the  seat  of  cauterization,  he 
maintained  that  the  inflanimatorj^  product  was  derived  exclusive]}^  from 
the  blood,  and  that  its  escape  from  the  blood-stream  depended  on  altera- 
tion of  the  ca})illary  wall.  He  regarded  the  dilatation  of  blood-vessels, 
which  occurs  soon  after  the  application  of  the  irritant,  as  a  result  of 
reflex  action,  and  attempted  to  prove,  by  specimens  of  keratitis  stained 
with  chloride  of  gold,  that  the  fixed  tissue-cells  remained  unaffected  by 
tlie  inflammation.  Strieker  maintained  the  opposite  view,  and  proved, 
in  silver-stained  specimens,  that  the  corneal  corpuscles  had  undergone 
changes  whicli  indicated  tliat  they  performed  an  active  part  in  the  in- 
flammation. Recklinghausen  resorted  to  a  very  ingenious  experiment 
to  establish  his  theory  regarding  the  origin  of  the  wandering  cells  in  the 
vascular  spaces  of  the  cornea.  He  cauterized  the  cornea  of  a  frog, 
excised  it  immediately,  and  kept  it  under  conditions  favorable  to  cell 
vegetation,  and  found,  later,  wandering  cells  in  the  vascular  spaces,  the 
origin  of  which  he  traced  to  tissue  proliferation  of  the  corneal  corpuscles 
after  excision ;  but  even  his  assistant,  F.  A.  Hoflfmann,  expressed  the 
opinion  that  the  cells  might  have  been  leucocytes  which  had  entered  the 
vascular  spaces  before  the  cornea  was  excised.  It  is  more  than  doubtful 
that  tissue  proliferation  would  take  place  in  an  excised  cornea,  even 
under  the  most  favorable  physical  conditions.  There  can  be  no  doubt 
whatever  that  the  primary  exudation  in  traumatic  keratitis,  as  in  all 
other  forms  of  acute  inflammation,  takes  place  from  inflamed  capillary 
vessels,  as  Cohnheim  has  demonstrated  so  beautifuU}' ;  but  this  constitutes 
onl}'  a  part  of  the  phenomena  which  characterize  inflammation  in  the 
cornea  and  all  other  tissues,  as,  later,  the  fixed  tissue-cells  participate  in 
the  process,  and  the  new  cells  derived  from  them  form  a  part  of  the  in- 
flammatory products.  The  parenchymatous  changes  are  even  more  im- 
portant than  the  vascular,  as  repair  after  subsidence  of  inflammation  is 
accomplished  exclusively  by  proliferation  of  the  fixed  tissue-cells. 
Eberth  has  demonstrated,  b}'^  his  accurate  histological  researches,  that 
the  corneal  corpuscles  near  an  eschar,  made  for  the  purpose  of  producing 
a  keratitis,  multiply  by  karyokinesis,  and  regeneration  is  effected  exclu- 
sively b}'^  the  embryonal  cells  derived  from  this  source.  The  corneal 
corpuscles  possess  a  high  vegetative  capacity,  resembling  in  this  respect 
the  connective  tissue,  to  which  they  bear  a  strong  resemblance,  having  a 
similar  embryological  origin,  and  receive  their  nutritive  supply  through 


INFLAMMATION    OF    NON- VASCULAR   TISSUE.  105 

a  system  of  lymph-cbannels  or  vascular  spaces  which  are  in  intimate 
relationship  with  the  sclerotic  vessels  at  the  border  of  the  cornea.  The 
plasma  or  lymph-channel  in  the  cornea  are  loosely  filled  with  a  liquid 
albuminoid  substance,  in  which  can  be  seen,  even  in  a  normal  condition, 
occasionally  a  Ij-mph-corpuscle.  In  artificial  keratitis  these  channels 
are  first  packed  with  leucocytes,  which  escape  from  the  congested 
capillaries  at  the  limbus  cornece,  enter  them  directly,  and  wander  toward 
the  seat  of  irritation  far  in  advance  of  the  new  blood-vessels.  Infiltra- 
tion of  the  cornea  with  leucocytes  gives  rise  to  cloudiness.  At  first 
Cohnheim  claimed  that  infiltration  of  the  cornea  alwaj'S  occurred  from 
the  periphery,  but  in  some  of  the  later  experiments  on  the  corneae  of 
spring  frogs  he  noticed  cell  accumulation  around  the  central  eschar  made 
with  a  sharp  pencil  of  nitrate  of  silver,  and,  as  he  was  absoluteh'  opposed 
to  the  idea  that  the  corneal  corpuscles  could  take  any  active  part  in  the 
process,  he  came  to  the  forced  conclusion  that  the  cellular  elements  of 
the  conjunctival  fluid  were  increased,  and  that  these  had  wandered  into 
the  cornea  through  the  lesion  at  the  centre.  Strieker  has  observed 
karyomitotic  changes  in  the  corneal  corpuscles  surrounding  a  central 
eschar  as  earl}-  as  three  hours  after  cauterization,  and  after  twenty-four 
to  forty -eight  hours  cell  proliferation  was  seen  to  be  present  all  around 
the  inflamed  area. 

From  what  different  authors  have  written  on  the  subject  of  artificial 
keratitis,  wliich,  of  course,  must  be  accepted  as  a  fair  representative  of 
the  clinical  forms  of  this  disease,  it  becomes  apparent  that  the  first 
evidence  of  inflammation  is  an  increased  amount  of  fluid  in  the  vascular 
spaces,  causing  distention  and,  consequentl}',  swelling  of  the  cornea.  As 
the  plasma  canals  become  distended  the  cells  lining  them  are  in  part  de- 
stroj'ed,  and  the  fluid  escapes  between  two  laminae  and  forces  them  partl}^ 
asunder.  (Fig.  41,  C,  C.)  At  this  time  the  endothelial  cells  and  corneal 
corpuscles  undergo  tissue  proliferation,  and  the  new  cells  form  part  of 
the  inflammatory'  product.  With  the  breaking  down  of  the  vascular 
spaces  resulting  in  lymph  stasis,  accumulation  of  lymph-corpuscles  also 
takes  place,  by  which  another  cellular  element  is  added  to  the  inflamma- 
tory product.  The  plasma  channels  and  artificially-formed  spaces 
between  laminae  are  now  blocked  with  leucocytes,  lymph-cori)uscles,  and 
embryonal  cells.  If  the  irritation  is  prolonged  for  a  sufficient  length  of 
time,  vascularization  of  the  inflamed  cornea  will  take  place  in  the  course 
of  one  or  two  weeks  by  the  formation  of  new  vessels  from  pre-existing 
sclerotic  vessels  at  the  corneal  border.  The  new  blood-vessels  grow  in 
the  direction  of  the  seat  of  irritation,  occupying  a  triangular  field,  with 
the  apex  directed  toward  the  centre,  the  base  corresponding  to  the  limbus 
corneae.     The  vascular  portion  of  such  a  cornea  is  called  a  pan n us.     In 


106 


PRINCIPLES   OF   SURGERY. 


suppurative  keratitis  the  emigration  corpuscles  undergo  fragmentation 
and  are  converted  into  pus-corpuscles ;  at  the  same  time  tlie  embryonal 
cells  exposed  to  the  action  of  the  pus-microbes  furnish  another  histo- 
logical source  for  pus  production.  The  fibrous  tissue  within  the  sup- 
purating area  necroses  on  account  of  the  disturbed  nutrition  and  the 
toxic  effect  of  the  pus-microbes  and  their  ptomaines,  and  an  abscess 
results.     Yascuhirization  of  an   inflamed   cornea   furnishes  one  of   the 


Fig.  41.— Artificial  Keratitls,  Kitten.    Silver-staining,  X  450.    {Hamilton.) 

A.  isolated  and  nucleated  cell ;  B,  a  group  of  such  still  retaining  something  of  the  shape  of  a  plasma 
canal ;  C,  C,  plasma  canals  breaking  into  fragments ;  D,  the  fibrous  basis  of  the  lamellae,  or  the  ground- 
substance. 

most  beautiful  illustrations  of  the  presence  of  protective  resources  in 
the  organism,  which,  when  called  upon  to  meet  different  emei'gencies, 
render  material  aid  in  the  prevention  or  limitation  of  destructive  proc- 
esses. Every  oculist  is  familiar  with  the  fact  tliat  extensive  suppurative 
keratitis  manifests  no  tendency  to  reparative  action  when  conditions  are 
present  tliat  retard  or  coinpletelv  prevent  the  formation  of  a  pannus. 
As  soon  as  the  process  of  repair  has  been  completed  the  new  vessels  dis- 


INFLAMMATION    OF   NON-TASCULAR   TISSUE.  107 

appear,  leaving  a  transparent  cornea  if  the  defect  has  been  within  the 
limits  of  the  regenerative  capacity  of  the  tissues ;  in  case  the  loss  of 
substance  has  been  too  great  for  complete  restoration  of  structure  and 
function,  healing  is  accomplished  b}'  the  formation  of  ordinar}-  cicatricial 
tissue,  which  results  in  the  formation  of  a  scar — a  permanent  opacity  of 
the  cornea.  In  keratitis  without  suppuration,  or  attended  by  a  limited 
ulceration,  the  cloudiness  of  the  cornea  resulting  from  cell  infiltration 
and  the  presence  of  embryonal  cells  in  moderate  abundance,  transparency 
is  restored  with  the  removal  of  the  wandering  cells  by  gi-anular  degenera- 
tion and  absorption,  or  their  return  into  the  circulation,  and  the  repair 
of  the  lesion  by  tlie  transformation  of  the  embryonal  cells  into  mature, 
perfect,  corneal  tissue. 

Cartilage. — Cartilage  is  a  structure  not  only  devoid  of  blood-vessels, 
but  also  of  any  kind  of  vascular  spaces  for  plasma  circulation.  Nutrition 
must  here  take  place  by  inter-  and  intra-  cellular  diffusion  of  plasma.  In 
its  structure  it  resembles  the  cornea.  On  account  of  the  absence  of  any 
direct  or  indirect  connection  of  cartilage  tissue  with  the  vessels  of  the 
perichondrium  all  regenerative  processes  are  slow  and  imperfect,  and  the 
inflammatory  lesions,  which  onl}'  occasionally  are  found  here  as  a  primary 
affection,  are  noted  for  their  chronicity.  Artificial  chondritis  was  studied 
b^-  Goodsir  and  Redfern.  Certain  parenchymatous  changes  were  noted  at 
different  times  after  cauterization  of  articular  cartilage.  They  consist 
essentially  in  the  enlargement  of  the  cartilage-cells,  with  increase  of  the 
nuclei,  or  of  peculiar  corpuscles  contained  in  them,  or  with  fatty  degen- 
eration of  their  contents  and  fading  or  similar  degeneration  of  their 
nuclei.  The  hj^aline  intercellular  substance  at  the  same  time  splits  up, 
and  softens  into  a  gelatinous  and  finely  molecular  and  dotted  substance. 
When  molecular  disintegration  or  ulceration  of  cartilage  takes  place,  the 
enlarged  cartilage-cells  on  the  surface  are  liberated,  and  the  cement-sub- 
stance disappears  in  a  similar  manner  after  having  undergone  liquefaction. 
Kiiss  stated  that  he  had  recognized,  in  articular  cartilage  under  the  influ- 
ence of  irritants,  certain  fibrous  transformations,  and  believed  that  he 
had  seen,  in  one  case,  changes  taking  place  within  the  cartilage-cells.  If 
articular  cartihige  be  examined  in  the  neighborhood  of  an  ulcerated  spot, 
a  complete  separation  of  tlie  fibres,  the  existence  of  which  in  its  lami- 
nated structure  was  demonstrated  by  Thin,  by  a  special  method  of 
silver-staining,  and  its  reversion  to  ordinary  white  fibrous  tissue  can  be 
readily  made  out. 

Weber  describes  new  vessels  as  extending  not  only  over  the  surface 
of  the  ulceratiug  cartilage,  but  afterward  penetrating  its  substance.  In 
long-standing  ulceration  of  cartilage  a  well-marked  pannous  condition  is 
usually  found  present,  which  has  resulted  from  the  development  of  new 


108  PRINCIPLES   OF   SURGERY. 

blood-vessels  from  the  vessels  of  the  perichondrium,  which  grow  in  the 
direction  of  the  inflammatory  focus  in  the  same  manner  as  in  keratitis. 
Defects  of  cartilage  caused  by  inflammation,  like  defects  resulting  from 
a  trauma,  are  only  partially  repaired  on  account  of  the  low  vegetative 
capacity  of  the  cartilage-cells,  and  the  product  of  tissue  proliferation  is 
transformed  into  connective  tissue. 

PHAGOCYTOSIS. 

It  has  been  known  for  a  long  time  that  absorbable  aseptic  tissues  in 
the  living  body  are  capable  of  removal  b}^  the  action  of  certain  cells. 
The  absorption  of  aseptic  catgut  ligatures  by  leucocytes  and  embryonal 
cells,  which  accumulate  around  it  and,  Inter,  inliltrate  it,  aflords  a  good 
illustration  of  this.  Metschuikoff  lias  introduced  the  term  phagocytosis 
to  designate  a  process  by  which  leucocytes  and  other  cells  remove  dead 
material  and  destroy-  or  digest  pathogenic  micro-organisms.  The  cells 
which  perform  tliese  functions  he  calls  phagocytes.  The  leucocytes  are 
called  mikropliagi,  and  the  fixed  tissue-cells,  which  are  capable  of  per- 
forming the  same  function,  makrophagi.  Pigment-granules,  minute 
fragments  of  tissue,  and  microbes  gain  entrance  into  a  cell,  either  by  the 
projections  wiiich  are  thrown  out  by  amoeboid  cells  surrounding  and 
inclosing  them  (intussusception),  or,  in  the  absence  of  amoeboid  move- 
ments, by  a  special  property  of  the  cells,  by  which  they  take  up  into 
their  protoplasm  solid  particles  of  various  kinds.  The  cells  which  are 
known  to  possess  phagocytic  properties  are  the  leucocytes,  mucous  cor- 
puscles, connective-tissue  cells,  endothelia  of  blood-vessels  and  13'mphatic 
vessels,  alveolar  epithelium  of  the  lungs,  and  the  cells  of  the  spleen, 
bone,  marrow,  and  lymphatic  glands.  Metschnikoff  studied  first  phago- 
cytosis in  the  tail  of  the  tadpole,  and  found  that  the  separation  of  this 
organ  at  the  time  this  animal  is  developed  into  a  frog  is  accomplished  b}'' 
leucocytes.  At  a  time  when  the  hind  legs  begin  to  bud  the  leucocytes 
migrate  into  the  tail,  and  at  the  point  where  separation  is  to  take  place 
they  attack  the  tissues,  minute  fragments  of  which  may  be  seen  in  the 
interior  of  their  protoplasm.  In  the  daphnia,  the  common  water-flea,  he 
studied  the  destruction  of  a  fungus  with  which  these  insects  .'ire  prone 
to  be  infected, — by  the  mikropliagi.  When  phagocytosis  proved  suceess- 
fnl  he  witnessed  the  destruction  of  the  fungus  in  the  interior  of  leuco- 
cytes ;  on  the  other  hand,  when  the  fungi  were  present  in  such  large 
numbers  that  the  leucocytes  were  unable  to  destroy  or  digest  them,  the 
daphnia  died.  Next,  he  investigated  phagocytosis  in  a  number  of 
diseases, — erysipelas,  anthrax,  relapsing  fever,  and  tuberculosis.  In 
erysipelas  the  cocci  are  first  attacked  by  the  leucocj^tes  filling  the  lymph- 
spaces,  and,  later,  by  the  fixed  connective-tissue  cells.     In  the  path  of 


PHAGOCYTOSIS.  109 

destruction  he  saw  leucocj'tes  loaded  with  cocci,  the  latter  showing 
various  stages  of  dissolution.  The  connective-tissue  cells  were  also 
engaged  in  the  removal  of  disintegrated  leucocytes.  In  fatal  cases  of 
erj'sipelas  the  streptococci  multiplied  with  such  great  rapidity  that  the 
phagocytes  were  unable  to  cope  successfully  with  the  disease.  Ribbert 
experimented  with  the  spores  of  aspergillus  and  mucor,  and  the  results 
were  such  that  he  claimed  that  spores  in  the  interior  of  leucocytes,  the 
connective  tissue  of  the  liver,  and  the  giant  cells  which  develop  in  the 
liver  and  in  the  lungs  are  destroyed,  but  that  their  destruction  is  not 
owing  so  much  to  phagocytic  action  of  the  cells  as  to  the  exclusion  from 
them  of  nourishment  for  the  spores,  particularly  of  ox3gen.  Laer 
injected  into  the  lungs  through  the  trachea  cultures  of  the  staphylo- 
coccus in  rabbits,  with  the  result  of  causing  a  catarrhal  inflammation. 
The  cocci  were  removed  by  leucocj'tes  and  the  embryonal  epithelia  of 
the  alveoli.  During  the  first  week  these  cells  contained  many  cocci,  but 
during  the  second  week  they  disappeared  in  the  cells,  and  the  animals 
recovered. 

Metschnikoff's  doctrine  of  phagoc3tosis  has  met  with  violent  oppo- 
sition by  a  number  of  eminent  pathologists,  and  foremost  among  them 
we  find  Banmgarten.  In  a  number  of  publications,  this  author  has 
taken  a  positive  and  firm  stand  against  the  claim  that  cells  have  the 
power  to  digest  or  destroy  the  microbes  which  inhabit  their  protoplasm. 
Holmfeld,  Bitter,  Prudden,  and  Nuttal  have  also  arra3'ed  themselves 
against  Metschnikoff.  With  some  modifications  Klebs  is  a  believer  in 
phagocj^tosis.  In  a  ver^'  interesting  paper  on  this  subject,  Osier  gives 
the  result  of  his  own  observations  on  the  phagoc3'tic  action  of  the  cells 
lining  the  bronchial  tubes  and  the  alveoli  of  the  lungs.  He  shows  very 
conclusively  how  minute  foreign  particles  are  eliminated  b3'  means  of 
the  phagocytic  action  of  the  cells.  In  connection  with  the  subject  of 
inflammation,  the  doctrine  of  phagocytosis  should  be  employed  in  a  wider 
sense  than  was  assigned  to  it  by  Metschnikoff".  In  the  first  place,  the 
accumulation  of  leucocytes  at  the  seat  of  inflammation  must  be  consid- 
ered in  the  light  of  a  mechanical  barrier,  an  attempt  to  protect  the  tis- 
sues against  infection.  Unfortunatel3%  in  acute  inflammation,  this  wall 
is  usually  more  apparent  than  real,  as  the  microbes  become  difl'used 
through  tlie  plasma-stream,  and  are  transported  by  the  leucocytes  them- 
selves ;  hence  the  progressive  nature  of  the  process.  The  connective- 
tissue  proliferation  proves  more  successful  than  emigration  in  limiting 
the  dissemination  of  micro-organisms  in  the  tissues,  as  the  new  cells,  as 
long  as  the3- remain  attached  to  the  matrix  which  produces  them,  remain 
stationar3-,  and  mechanically  block  the  avenues  through  which  dissem- 
ination takes  place.     It  is  the  impermeable  wall  of  granulation  tissue 


110  PRINCIPLES   OF    SURGERY. 

which  surrounds  a  suppurating  depot,  Avhich  finally  limits  suppurative 
inflammation.  In  the  next  place,  the  phagocytes  are  scavengers  which 
remove  foreign  dead  particles  from  the  tissues.  Langhans  was  tlie  lirst 
to  show  that  extravasated  blood  did  not  simply  disintegrate  and  disap- 
pear, but  that  the  connective-tissue  elements  were  actively  at  work,  and 
that  many  of  the  colored  corpuscles  disappear  in  their  interior.  Rosen- 
berger  implanted  stained  aseptic  tissue  into  the  abdominal  cavity 
of  animals,  and,  on  examining  the  parts  a  few  weeks  later,  found 
that  not  only  had  the  tissues  been  completely  removed  by  leucocytes, 
but  he  was  able  to  follow  the  course  of  the  leucocytes,  after  the}^  had  left 
the  feeding-gi'ound,  by  colored  lines,  all  of  which  were  seen  to  radiate 
from  the  place  where  the  stained  tissue  had  been  fixed.  In  different 
pathological  conditions  where  tissue  proliferation  was  in  process,  Klebs 
could  find  positive  evidence  that  wandering  cells  wliich  had  undergone 
fragmentation  had  been  appropriated  by  the  embryonal  cells  as  food,  as 
fragments  of  the  nuclear  chromatin  of  the  leucocytes  could  be  discov- 
ered in  the  protoplasm  of  the  new  cells.  In  the  reparative  process 
which  follows  the  subsidence  of  inflammation,  a  great  deal  of  cellular 
debris  is  to  be  removed,  and  this  work  is  performed  by  the  phagocj'^tes, 
notably  by  tiie  fixed  tissue-cells  in  a  state  of  proliferation.  The  vege- 
tative capacity  of  the  cells  is  augmented  by  the  reception  into  their 
protoplasm  of  nutritive  material  furnished  them  by  cells  which  have 
succumbed  in  the  struggle.  MetschnikolT  believed  that  the  destruction 
of  micro-organisms  in  the  interior  of  phagocytes  was  an  active  process, 
and  that  the  protoplasm  had  a  sort  of  a  digestive  action  upon  them.  To 
prove  the  correctness  of  this  supposition,  he  made  some  experiments 
with  the  bacillus  of  tuberculosis.  He  injected  a  pure  culture  of  the 
bacilli  into  the  subcutaneous  tissue  of  white  rats,  and,  later,  produced 
artificially  suppuration  at  the  seat  of  injection.  Two  months  later  he 
found  bacilli  in  the  pus-corpuscles  in  an  unchanged  condition,  and  with- 
out having  lost  their  power  of  reproduction.  As  in  other  experiments 
he  had  witnessed  the  destruction  and  disappearance  of  the  same  bacillus 
in  living  cells,  he  concluded  that  phagocytosis  is  an  active  process  which 
can  only  take  place  in  a  living  cell,  and  is  suspended  with  the  death  of 
the  cell.  There  are  few  at  this  time  who  regard  the  destruction  and  dis- 
appearance of  microbes  in  phagocytes  as  an  act  of  digestion.  If,  how- 
ever, microbes  in  the  interior  of  phagocytes  are  rendered  harmless,  or 
disintegrate  and  disappear,  this  fact  is  an  important  one,  and  it  is  im- 
material in  what  way  this  result  is  obtained,  whether  the  microbes  are 
digested  bj'^  the  protoplasm,  or  whether  some  chemical  substance  in  the 
cell-body  exerts  an  inhibitory  effect  upon  them,  or,  finally,  whether  for 
want  of  a  proper  nutrient  material  they  are  starved,  as  it  were.     The 


CHRONIC    INFLAMMATION. 


Ill 


results  of  experimental  research  have  furnished  positive  evidence  that 
infective  processes  terminate  most  favorably  where  the  conditions 
described  as  phagocytosis  are  accomplished  most  satisfactorily. 

When  the  struggle  between  a  microbe  and  a  phagocyte  turns  out  in 
favor  of  the  latter,  the  microbe  does  not  multiply  in  the  protoplasm,  or 
ceases  to  do  so  before  the  protoplasm  is  destroyed,  and,  as  the  microbe 
cannot  leave  without  dissolution  of  the  cell,  it  remains  within  its  narrow 
confinement  and  is  destro^'ed,  either  by  some  as  yet  unknown  chemical 
substance  or  dies  from  starvation  ;  in  either  event  the  vitality  of  the 
cell  is  not  impaired,  and  the  microbe  disintegrates  and  disappears. 
(Fig.  42,  A.)  If  the  conditions  for  the  growth  and  development  of  the 
microbe  in  the  protoplasm  of  the  cell  are  more  favorable,  intra-cellular 
multiplication  of  the   microbe   takes   place,  the   ptomaines   which   are 


Fig.  42.— Phagocytosis.    Struggle  between  Anthrax  Bacillus  and  Leucocyte, 

A,  successful  phagocytosis ;  B,  unsuccessful  phagocytosis. 

eliminated  produce  coagulation  necrosis  in  the  protoi)lasm,  the  cell 
disintegrates,  and  the  intra-cellular  culture  is  liberated  in  an  active  con- 
dition (Fig.  42,  B).  In  cases  of  unsuccessful  warfare  of  the  phagocytes 
against  invading  micro-organisms,  the  mechanical  obstruction  composed 
of  emigration  corpuscles  and  embrj^onal  cells  is  broken  down,  and  the 
rapid  increase  of  micro-organisms  at  the  seat  of  inflammation  gives  rise 
to  extensiA'e  local  and  often  general  infection.  From  a  practical  stand- 
point it  can  be  said  that  all  therapeutic  measures  which  influence  favor- 
ably the  process  of  phagocytosis,  in  the  broadest  meaning  of  this  word, 
are  calculated  to  exert  a  potent  influence  in  arresting  or  limiting  infective 
processes. 

CHRONIC   INFLAMMATION. 

Chronic  inflammation  differs  from  the  acute  form  onl^'  in  degree. 
The  vascular  changes  which  have  been  described  come  on  slowlj^,  and 


112  PRINCIPLES   OF    SURGERY. 

are  never  as  mai*ked  as  in  acute  inflammation,  and  on  this  account  the 
emigration  of  blood-corpuscles  occurs  slowly,  and  in  some  instances  it 
is  entirely  wanting.  The  inflammatory  product  is  largely,  and  in  some 
cases  exclusivel}',  composed  of  embryonal  cells  derived  from  fixed 
tissue-cells.  The  noxae  which  excite  chronic  inflammation  are  such  that 
exert  their  deleterious  effect  more  on  the  tissue-cells  directly  than  the 
capillary  vessels.  Their  primary  action  on  the  tissues  consists  in 
increasing  the  vegetative  capacity  of  the  cells  ;  hence,  niatun;  cells  are 
transformed  into  embr3'onal  or  granulation  tissue  and  remain  in  this 
condition  as  long  as  the  noxae  exist,  and  retain  their  pathogenic  qualities 
or  otherwise  until  the  new  ceWs  undergo  retrograde  inetsunorphosis.  If 
in  a  chronic  inflammation  degeneration  of  the  embryonal  cells  has  not 
taken  place,  and  the  primary  cause  has  ceased  to  act,  the  new  tissue  is 
either  removed  by  absorption  or  is  converted  into  mature  tissue,  in 
Avhich  event  the  inflammation  has  resulted  in  hyperplasia.  S^'philitic 
gummata,  which  are  composed  almost  exclusively  of  embryonal  tissue, 
disappear  promptly  under  a  vigorous  antisyphilitic  treatment,  because 
by  such  treatment  the  micro-organisms  which  have  caused  the  lesion 
are  either  destroyed  or  at  least  have  been  deprived  for  the  time  being  of 
their  pathogenic  properties. 

Chronic  inflammation  is  represented  by  that  large  class  of  affections 
which  are  included  under  the  name  gy-anulomala.  These  swellings,  irre- 
spective of  their  primary  microbic  cause,  are  composed  of  what  is  known 
as  granulation  tissue.  Some  pathologists  have  been  inclined  to  classify 
them  with  tumors,  because  their  development  is  seldom  attended  by 
well-marked  symptoms  of  inflammation,  and  in  their  methods  of  regional 
and  general  dissemination  they  bear  a  close  resemblance  to  the  malignant 
tumors.  Their  obstinacy  to  successful  treatment  does  not  depend  upon 
any  malignant  qualities  of  the  tissues  of  which  they  are  composed,  but 
upon  the  difficulty  of  eliminating  or  rendering  inert  the  primary  cause 
by  internal  medication  or  operative  procedures. 

All  granulomata  are  inflammatory  in  their  origin,  and  under  the 
microscope  present  all  the  characteristic  appearances  of  inflammation. 
Histologicall}'  the}'  are  composed  of  embrN'onal  cells  which  correspond 
to  the  type  of  the  tissues  in  which  or  from  which  they  have  developed. 
In  a  tubercular  nodule  we  find  giant  cells,  epithelioid  cells,  the  ordinary 
granulation  cell,  and  leucocytes.  Actinomycotic  swellings  are  comi)osed 
almost  exclusively  of  embryonal  connective  tissue.  Many  of  the  granulo- 
mata contain  Ehrlich's  plasma-cells  (Mastzellen),  of  unknown  origin, 
composed  of  a  finely-granular  mass  arovmd  a  vesicular  nucleus.  On 
staining  with  aniline  colors,  the  nucleus  remains  unchanged,  while  the 
granules  are  deeply  stained.     The  cells  are  about  the  size  of  a  leucocyte, 


CHRONIC    INFLAMMATION.  113 

either  spherical  or  somewhat  elongated  in  shape.  In  some  cases  the 
outer  portion  of  the  inflammatory  product,  being  sufficient!}^  remote 
from  the  infected  area,  is  converted  into  a  firm  connective-tissue  capsule, 
which  limits  tlie  extension  of  infection,  while  in  its  interior,  from  the 
presence  of  the  specific  micro-organisms,  but  probabh'  more  on  account 
of  inadequate  blood-supply  the  tissues  undergo  rapid  retrograde 
degenerative  changes. 

Secondary-  infection  in  a  granuloma,  either  through  the  circulation, 
or,  what  is  more  common,  from  without,  through  some  minute  infection- 
atrium,  is  a  not  uncommon  occurrence.  Secondary-  infection  almost 
alwa3's  means  localization  of  pus-microbes  in  the  granulation  tissue  and 
a  breaking  down  of  the  latter  into  pus-corpuscles.  The  serious  conse- 
quences which  follow  suppurative  inflammation  of  a  gumma  developing 
after  incision  made  upon  a  wrong  diagnosis  is  well  known.  Infection  of 
a  large  tubercular  depot  with  pus-microbes  after  incision  without  proper 
antiseptic  precautions,  or  after  spontaneous  evacuation,  is  followed  by 
destruction  of  the  remaining  gramilations,  profuse  suppuration,  and  not 
infrequently  by  death  from  sepsis.  Actinomvcosis  gives  rise  to  a  large 
granuloma  without  any  tendency  to  suppuration  until  infection  takes 
place  with  pus-microbes,  when  the  granulations  melt  awa}'  rapidly, 
leaving  a  deep  ulcer  with  ragged,  undermined  margins,  and  a  speedy 
extension  of  the  combined  infective  processes  following  in  its  course  the 
connective  tissue. 

The  secondary  infection,  however,  may  prove  beneficial  and  become 
the  means  of  complete  elimination  of  the  products  and  micro-organisms 
of  the  primary  infection.  In  this  way  a  localized  tubercular  lesion  is 
sometimes  cured  spontaneously  by  suppuration.  A  suppurative  inflam- 
mation of  a  tuberculous  gland  of  the  neck  is  often  followed  bj^  complete 
removal  of  the  bacilli-containing  tissues  and  a  permanent  cure.  All 
chronic  inflammatory  processes  are  attended  by  recurring  attacks  of 
acute  exacerbations.  If  during  these  attacks  in  the  periphery  of  the 
chronically-inflamed  area  a  more  active  cell  proliferation  is  initiated,  the 
conditions  for  a  more  successful  phagocytosis  are  improved  and  the 
acute  attack  has  proved  a  curative  measure. 

The  surgeon  often  resorts  to  measures  which  result  in  the  transfor- 
mation of  chronic  into  an  acute  inflammation,  in  imitation  of  nature's 
efl^orts  in  the  same  direction.  In  illustration  of  this,  I  will  only  mention 
ignipuneture.  The  fenestration  of  a  chronic  inflammator}-  swelling 
under  strict  antiseptic  precautions  has  proved  a  valuable  therapeutic 
measure  by  securing  drainage,  but  more  especial!}'  because  around  each 
tubular  eschar  made  with  the  needle-point  of  a  Paquelin  cautery  a  zone 
of  active  tissue  proliferation  is  created,  and  the  new  tissue,  by  under- 


Ill:  J'KINCII'LKS   OF    SURGKKV. 

going  transfonnation  into  cicatricial  tissue,  serves  a  usel'iil  purpose  in 
starving  out  microbes  that  have  escaped  the  cautery.  Anotlier  instruc- 
tive instance  of  the  benefits  which  accrue  from  the  substitution  of  an 
acute  for  a  clironic  inflammation  is  found  in  tlie  use  of  jequirity  in 
oplithalmic  practice.  The  powdered  bean  or  some  otlier  preparation  of 
tliis  drug,  when  brought  in  contact  witli  the  conjunctiva,  produces  a 
violent  inflammation  which  has  frequently  proved  a  curative  measure  in 
the  treatment  of  trachoma  ami  some  forms  of  pannus  of  tlie  cornea. 

One  of  the  ways  in  whicli  an  acute  inflammation  acts  beneficially  in 
promoting  the  process  of  resolution  in  tissues  tlie  seat  of  a  chronic 
inflammation  is  bj^  its  stimulating  action  on  the  capillary  vessels.  The 
active  h^'per^emia  ma^-  become  the  means  of  clearing  partially-obstructed 
capillary  vessels  of  implanted  colorless  corpuscles,  and  thus  remove  from 
the  weakened  tissues  not  only  the  mechanical  causes  which  have  main- 
tained the  chronic  congestion,  but  also  the  intra-vascular  cause  of  the 
inflammation — the  microbes.  When  the  infected  corpuscles  reach  the 
general  circulation  there  is  a  chance  for  more  effective  phagoc_ytosis  and 
elimination  of  the  microbes  through  one  or  more  of  the  excretory  organs. 

SYMPTOMS  AND  DIAGNOSIS  OF  INFLAMMATION. 
For  practical  purposes,  inflammation  may  be  divided  into  acute, 
subacute,  and  chronic,  according  to  the  intensity  of  symptoms  and  the 
time  required  to  reach  one  of  its  terminations.  The  nature  of  the  pri- 
mary cause  determines  the  course  and  nature  of  the  inflammation.  The 
microbes  of  suppuration,  erysipelas,  anthrax,  glanders,  tetanus,  and 
gonorrhoea  cause  acute  affections,  while  the  micro-organisms  of  tubercu- 
losis, lepra,  and  actinomycosis  cause  lesions  which  are  noted  for  their 
chronicity.  Acute  inflammation  may  become  subacute  and  finally 
chronic,  as  in  suppurative  osteomyelitis,  where,  if  the  disease  is  multiple, 
in  the  first  bone  affected  it  pursues  a  very  acute  course  ;  while  often  in 
the  successive  bones  attacked  it  is  less  intense,  and  not  infrequently  in 
the  last  bone  involved  it  appears  as  a  chronic  affection.  A  chronic  in- 
flammation may  be  followed  by  a  subacute  or  acute  attack,  as  is  fre- 
quently observed  in  tubercidosis  complicated  by  secondary  infection 
with  pus-microl)es.  •  In  acute  inflammation  the  local  and  general  symp- 
toms are  so  well  marked  that  no  difficulties  are  in  the  way  of  recogniz- 
ing its  existence,  and  it  only  remains  to  decide  upon  its  cliarncter.  The 
fever  which  attends  the  inflammation  is  only  a  symptom,  and  indicates 
the  introduction  into  the  general  circulation  of  phlogistic  substances 
from  the  products  of  exudation  or  the  fixed  tissue-cells  which  have 
undergone  pathological  changes.  Microbes  that  cause  acute  inflamma- 
tion differ  greatly  as  to  the  amount  or  intensity  of  action  of  the  phlo- 


SYMPTOMS    AND    DIAGNOSIS    OF    INFLAMMATION.  115 

gistic  substances  which  they  produce  in  the  iuliamed  tissues  affected  ; 
also  exert  an  important  influence  in  modifying  the  febrile  disturbance. 
Suppuration  caused  by  the  micrococcus  pyogenes  tenuis  is  not  attended 
by  so  high  a  temperature  as  when  produced  by  tlie  staphylococcus  or 
streptococcus.  The  rise  in  temperature  which  accompanies  inflammation 
is  due  either  to  the  introduction  into  the  circulation  of  fibrin  ferment 
resulting  from  the  destruction  of  leucocytes  or  the  production  of  pto- 
maines b^'  the  specific  action  of  microbes  on  the  tissues,  which  act  as 
phlogistic  substances  when  introduced  into  the  general  circulation, — a 
fact  which  has  been  abundantly  demonstrated  by  clinical  observation 
and  experimental  research.  As  soon  as  the  causes  which  have  produced 
the  rise  in  temperature  in  inflammation  have  been  rendered  inert  by  phago- 
cytosis, or  have  been  eliminated  with  the  removal  of  the  inflammatorj- 
product,  the  fever  subsides.  The  general  disturbances,  such  as  headache, 
vomiting,  loss  of  appetite,  thirst,  and  the  ever-present  feeling  of  lassitude 
which  attends  acute  inflammation  of  all  kinds,  are  caused  b}^  the  fever 
and  the  presence  of  toxic  substances  in  the  blood.  The  s^-mptoms  of 
inflammation,  which  have  been  described  at  length,  must  be  studied  sep- 
arately and  conjointl}'  in  each  form  of  inflammation,  and  their  individual 
and  mutual  significance  carefully  estimated.  A  local  rise  in  temperature 
is  of  more  diagnostic  value  in  ascertaining  the  existence  of  inflammation 
than  fever,  as  the  latter  can  be  caused  by  the  absorption  of  fibrin  ferment 
from  any  causes  which  destro}^  the  colorless  blood-corpuscles  and  the 
absorption  of  the  products  of  tissue  disintegration  in  malignant  tumors  ; 
while  a  permanent  increase  of  the  temperature  at  the  seat  of  the  disease 
denotes  almost  infallibly  the  existence  of  inflammation.  In  reference  to 
the  extension  of  the  inflammatory  process,  it  can  be  said  that  this  will 
be  influenced  b}-  the  anatomical  structure  of  the  part  involved  and  the 
manner  of  diffusion  of  the  microbe  which  causes  the  inflammation.  If  a 
mucous  or  serous  surface  is  affected,  infection  is  prone  to  spread  rapidl}^ 
b}'  continuit}^  of  tissue  and  the  mechanical  dissemination  of  the  microbes 
on  the  siirface  in  the  mucous  secretion,  and  b}'  the  movements  of  one 
serous  surface  upon  the  other.  In  er3'sipelas  the  inflammation  spreads 
rapidly,  as  the  microbe  is  diffused  through  the  Ij-mphatics  and  connective- 
tissue  spaces.  In  phlegmonous  inflammation  the  pus-microbes  find  no 
mechanical  barriers,  and  are  rapidly  distributed  OA'er  a  larger  area 
through  the  connectiA'e-tissue  spaces.  The  same  manner  of  diffusion  is 
observed  in  anthrax  if  the  bacillus  finds  ingress  into  a  part  supplied 
with  an  abundance  of  loose  cellular  tissue,  while  the  disease  remains 
circumscribed  and  presents  itself  in  an  indurated  form  if  it  is  located 
in  tissues  which  do  not  present  such  favorable  anatomical  conditions  for 
extension  of  the  local  invasion.     The  nature  of  the  inflammatory  product 


116  PRINCIPLES   OF    SURGERY. 

ahviiys  answers  to  the  specific  action  of  the  microbe  as  the  tissues 
which  caused  the  inflammation.  Thus,  an  inflammation  caused  by  pus- 
microbes  will  result  in  the  formation  of  pus ;  while  the  microbes  which 
produce  chronic  inlhunmation,  as  a  rule,  onl}^  convert  the  pre-existing 
mature  into  embryonal  tissue.  The  microbes  which  have  a  short  exist- 
ence in  the  tissues  may  give  rise  only  to  intense  hyperremia  and  a  mod- 
erate emigration  of  the  colored  blood-corpuscles,  as,  for  instance,  the 
streptococcus  of  erysipelas.  The  genuine,  uncomplicated  erysipelatous 
inflammation  is  of  such  short  duration  that  perfect  restoration  of  the 
parts  is  accomplished  in  a  few  daj's. 

PROGNOSIS. 

The  most  favorable  termination  of  inflammation  is  resolution,  with 
restitutio  ad  integrum  of  structure  and  function  of  the  tissues  which 
were  the  seat  of  the  inflammatory  process.  Resolution  is  only  possible 
if  the  emigration  of  blood-corpuscles  is  moderate  in  quantity  and  none  of 
the  cellular  elements  of  the  exudate  are  transformed  into  pus-corpuscles. 
If  exudation  take  place  rapidlj',  the  connective-tissue  spaces  are  com- 
pletely blocked  with  the  emigration  corpuscles  and  the  products  of 
coagulation  necrosis,  which  seriously  impairs  or  completely  arrests 
plasma  circulation,  and,  by  pressure  upon  the  l)lood-vessels,  may  interfere 
with  the  capillary  circulation  to  such  an  extent  as  to  cause  necrosis. 
Resolution,  as  has  been  previousl}'  stated,  signifies  that,  after  subsidence 
of  the  symptoms  of  inflammation,  the  part  is  left  in  a  condition  capable 
of  removing  the  inflammatory  product  and  of  repairing  the  damage  done. 
Many  of  the  leucocytes  which  have  retained  their  vitalit}''  immigrate 
back  into  the  general  circulation  either  through  the  walls  of  capillaries 
or,  what  is  more  frequent,  through  the  lymphatic  S3^stem.  The  remain- 
ing leucocytes  and  colored  corpuscles  undergo  degeneration  and  are 
removed  by  absorption.  Fibrin  which  has  formed  in  the  tissues  is  trans- 
formed into  a  granular  mass,  and  is  removed  in  a  similar  manner. 
Embr^'onal  cells  which  have  become  detached,  or  have  been  damaged  by 
the  inflammation,  are  also  removed  b}^  absorption  after  they  have  under- 
gone granular  degeneration.  The  transudation  is  removed  by  absorp- 
tion as  soon  as  capillary  circulation  is  restored  and  the  connective-tissue 
spaces  have  been  cleared  of  their  cellular  contents.  The  capillar^'-  wall 
is  repaired,  and  an^^  tissue  defects  are  restored  b}^  proliferation  of  the 
fixed  tissue-cells.  The  inflammator}'  ex\idate  ma}-  prove  a  source  of 
danger  when,  by  its  mechanical  pressure,  it  interferes  with  the  function 
of  important  organs,  as  the  brain,  heart,  or  lungs.  A  moderate  transu- 
dation within  the  skull  from  inflammation  of  any  of  the  meninges  can 
produce   death  from  compression  of  the  brain;  a  pericardial  effusion, 


TREATMENT.  117 

when  sufficient  in  amount  to  interfere  mecliauica,!!}^  with  the  action  of 
the  lieart,  causes  death  by  syncope  ;  and  a  copious  effusion  into  the 
pleural  cavity,  especialh'  if  it  come  on  rapidly,  may  impair  respiration 
to  such  an  extent  as  to  result  in  death  from  apnoea.  A  slight  croupous 
exudation  upon  the  vocal  cords  or  oedema  about  the  entrance  to  the 
larynx  destroys  life  bj-  preventing,  in  a  purely  mechanical  way,  the  en- 
trance into  the  lungs  of  an  adequate  quantit}'  of  air.  Inflammation  is 
greatly  modified  by  the  age  and  general  condition  of  the  patient.  Infants 
and  persons  advanced  in  yeiivs  possess  little  power  of  resistance,  and, 
when  attacked  b^^  inflammation,  the  disease  is  prone  to  become  diffuse 
and  lead  to  serious  pathological  changes.  The  same  can  be  said  of 
persons  who  have  been  debilitated  by  antecedent  diseases  or  intemperate 
habits.  The  greatest  danger  in  the  different  forms  of  inflammation,  as 
far  as  life  is  concerned,  consists  in  the  introduction  into  the  general  cir- 
culation of  septic  material  produced  in  the  inflamed  part  b}'  the  action 
of  microbes  on  the  tissues.  This  general  infection,  occurring  in  the 
course  of  a  localized  inflammation,  appears  eitlier  as  a  sj-mptomatic  fever, 
which  disappears  with  the  subsidence  of  the  local  process,  or  as  a  pro- 
gressive septicEemia,  pygemia,  or  septico-pysemia.  The  latter  diseases 
will  be  considered  in  separate  chapters.  Tubercular  affections  are  ahvaj'S 
attended  by  the  danger  incidejit  to  extension  of  the  process  to  other 
organs  b}*  dissemination  of  bacilli  through  the  lymphatic  channels  or 
blood-vessels.  Chronic  suppuration  finally  causes  am3loid  degeneration 
of  important  organs,  and  death  ensues  from  this  cause.  In  summing  up 
what  has  been  said  nnder  this  head,  it  is  evident  that  the  prognosis  rests 
mainly  upon  the  intrinsic  pathogenic  qualities  of  the  microbe  which  has 
caused  the  inflammation;  the  anatomical  structure,  location,  and  physio- 
logical importance  of  the  part  or  oi'gan  inflamed  ;  the  general  condition 
of  the  patient,  and  the  accessibility  to  and  feasibility  of  treating  the 
disease  by  direct  radical  surgical  means. 

TREATMENT. 

As  inflammation  per  se  is  no  disease,  but  an  effort  on  the  part  of  the 
organism  and  the  tissues  affected  to  eliminate  or  render  harmless  the 
primary  cause,  the  treatment  must  be,  in  each  individual  case,  purely 
S3'mptomatic.  A  proper  appreciation  of  the  nature  and  tendencies  of 
inflammation  is  an  essential  prerequisite  to  rational  treatment.  In 
surgery-  the  prophylactic  treatment  of  inflammation  is  the  most  important 
and  satisfactory.  The  prevention  of  inflammation  in  accidental  and  oper- 
ation wounds  by  strict  antiseptic  precautions  has  made  modern  surgerj' 
what  it  is.  The  surgeon  has  it  now  in  his  power,  b}'  resorting  to  anti- 
septic measures,  to  prevent  the  innumerable  and  formerly  too  often  fatal 


118  PRINCIPLES   OF    SURGERY. 

wound  complications.  Lister  has  inaugurated  a  new  era  in  surgery,  and 
his  work,  as  w^ell  as  that  of  his  early  enthusiastic  followers,  has  been  the 
means  of  saving  annually  thousands  of  lives.  The  mortality  of  even 
the  most  desperate  operations  where  the  antiseptic  treatment  can  be 
followed  to  perfection  has  been  so  much  reduced  that  operative  surgery 
has  received  a  new  impetus,  and  operations  are  devised  and  put  in  prac- 
tice almost  daily  which  formerl}'  would  have  been  looked  upon  as  a 
freak  of  imagination  or  the  outcome  of  a  diseased  brain.  The  prophy- 
lactic treatment  of  inflammation  in  dealing  with  wounds,  or  other  avenues 
through  Avhich  infection  can  take  place,  consists  of  securing  for  the 
place  deprived  of  the  effective  protection  against  the  entrance  of  patho- 
genic micro-orgnnisms — the  intact  skin  or  mucous  meml)rane — an  aseptic 
condition  by  antiseptic  measures,  and  to  bring  in  contact  with  it  only 
things  that  have  been  thoroughly  sterilized. 

In  inflammation  without  an  external  tangible  infection-atrium  we 
must  take  it  for  granted  that  microbes  have  entered  the  circulation 
through  slight  defects,  the  existence  of  which,  perhaps,  the  patient  does 
not  remember,  and  which  have  left  no  appreciable  marks  of  their  former 
existence,  or  infection  has  taken  place  through  some  of  the  appendages 
of  the  skin,  or  through  a  mucous  membrane,  with  localization  of  the 
microbes  in  a  part  or  organ  previously  prepared  for  their  reception  and 
growth ;  that  is,  in  a  location  presenting  a  locus  minoris  resistentiae. 

Recognizing  the  fact  that  inflammation,  wherever  it  occurs,  is  pro- 
duced by  the  action  upon  the  vessel-wall  and  the  tissues  outside  of  it  of 
specific  micro-organisms,  it  would  appear  that  the  most  rational  indica- 
tion for  treatment  would  be  to  resort  to  such  means  wdiich  would  destroy 
the  microbes  in  the  tissues  as  soon  as  their  presence  is  manifested  by  their 
action.  This  would  imply  the  saturation  of  the  inflamed  tissues  with  ger- 
micidal solutions,which  from  laboratory  experiments  are  known  to  be  effec- 
tive in  destro^'ing  such  microbes  ;  hence,  it  has  been  advised  to  resort  to 

Parenchymatous  Injections. — This  method  of  treatment  was  strongly 
advised  and  extensivel}^  practiced  b3"  Heuter  long  before  the  direct 
relationship  between  certain  microbes  and  definite  forms  of  inflammation 
had  been  demonstrated.  Heuter  claimed  that  ever}"  inflammation  was 
caused  by  certain  iioxae  introduced  from  w'ithout,  and  which  he  aimed  to 
destroy  by  saturating  the  inflamed  tissues  with  an  antiseptic  solution. 
His  favorite  remed}'^  was  a  3-  to  5-per-cent,  solution  of  carbolic  acid. 
The  instrument  which  he  used  was  an  ordinar}^  Pravaz  syringe,  with  a 
long  needle  provided  with  a  number  of  small  lateral  openings.  In  adults 
he  injected  as  much  as  10  grammes  at  a  time  of  a  3-per-cent,  solution.  In 
using  this  method  in  the  treatment  of  large,  granulating,  tubercular  foci 
he  emploj^ed  Avhat  he  termed  an  infusor,  composed  of  a  graduated  glass 


TREATMENT.  1 1  9 

cylinder,  joined  with  the  needle  by  means  of  a  rubber  tube.  By  this 
method  of  injection  the  fluid  diffused  itself  through  the  soft,  granular 
mass  by  its  own  weight.  In  the  treatment  of  tubercuhir  lesions  Heuter 
claimed  for  the  parenchymatous  injections  of  carbolic  acid  great  curative 
powers.  Rational  as  this  method  of  treatment  appears,  it  has  not  yielded 
the  results  tliat  were  anticipated.  The  living  tissues  cannot  be  compared 
with  a  test-tube.  IS^itrate  of  silver,  iodine,  permanganate  of  potassa, 
corrosive  sublimate,  and  other  potent  germicidal  agents  have  been  used 
since,  but  tlie  results,  oi)  the  whole,  have  been  anything  but  satisfactory. 
If  this  method  of  treatment  is  to  be  successful  in  the  treatment  of  acute 
inflammation,  it  n)ust  be  instituted  at  an  early  stage,  at  a  time  when  only 
a  limited  area  of  tissue  has  been  infected,  as,  under  such  circumstances, 
if  the  area  of  infection  could  be  accurately  outlined,  it  would  be  possible 
to  saturate  the  tissues  with  an  antiseptic  solution  without  running  the 
risk  of  killing  the  patient  Iw  administering  a  toxic  dose  of  the  drug 
employed,  which  might  be  the  case  if  a  larger  area  were  treated  in  a 
similar  manner.  If  we  remember  that  the  microbes  are  diffused  through- 
out the  entire  exudation,  and  constitute  the  most  important  element  of 
the  inflammatory  product,  it  is  easy  to  understand  that  sterilization  of 
the  inflamed  tissues  by  means  of  parench3'matous  injections  is  not  an 
easy  task,  and  we  are  then  in  a  position  to  realize  why  this  method  of 
treatment  has  not  proved  more  uniforml}'  successful.  Most  of  the  germi- 
cidal agents  heretofore  eniplo3'ed  in  this  manner,  when  brought  in  contact 
with  the  tissues,  form  compounds  which  prevent  further  diffusion,  and 
therefore  each  needle-puncture  sterilizes  only  a  very  small  portion  of  the 
inflamed  district.  It  is  possible  that  in  the  future  non-toxic,  but  at  the 
same  time  effective  germicidal,  substances  will  be  discovered  which  can 
be  used  in  larger  quantities,  and  in  this  event  the  treatment  of  inflamma- 
tion by  parenchymatous  injections  will  have  a  wide  range  of  application, 
and  will  be  practiced  with  better  success.  At  present  this  method  has  a 
limited  field  of  application  in  the  treatment  of  the  various  forms  of  in- 
flammation. Under  no  circumstances  should  the  amount  of  the  drug 
iTsed  exceed  the  dose  which  it  would  be  safe  to  administer  internally,  and 
the  danger  of  a  poisonous  dose  should  be  remembered  in  repeating  the 
injection.  An  ordinary  hypodermic  syringe  with  a  long  needle  can  be 
used  in  making  the  injection.  That  the  needle  and  sj^'inge  should  be 
perfectly  aseptic  is  to  be  understood  as  a  matter  of  course,  as  unclean 
instruments  have  often  been  the  means  of  conveying  a  fatal  disease. 
Multiple  punctures  are  to  be  preferred,  as  in  this  manner,  1)3'  using  the 
same  amount  of  fluid,  more  tissue  can  be  saturated  than  bv  a  single 
puncture.  Before  making  the  punctures  the  surface  must  be  disinfected. 
The  object  should  be  to  bring  the  antiseptic  solution  in  contact  with  as 


120  PHINCirLES    OF    SURGERY. 

much  of  the  injected  tissues  as  possible,  and  if  the  disease  show  a  ten- 
dency to  spread  it  is  advisable  to  go  beyond  the  zone  of  infection,  as, 
for  instance,  in  cases  of  erysipelas  and  anthrax.  Many  accessible  tuber- 
cular aftections  are  greatl}^  benefited  ])y  parenchymatous  injections  of 
carbolic  acid.  Kecently,  intra-articulur  and  parenehynuitous  injections 
of  iodoform  have  been  strongly  recommended  in  the  treatment  of  articu- 
lar and  other  forms  of  surgical  tuberculosis. 

Antiphlogistic  Treatment. — ^An  erroneous  conception  of  the  nature 
and  tendencies  (jf  intlammation  has  for  centuries  induced  the  ablest 
teachers  and  practitioners  to  advocate  and  practice  what  they  termed  the 
antiphlogistic  treatment  of  inflammation.  This  included  blood-letting, 
cupping,  leeching,  and  the  internal  use  of  emetics  and  cathartics.  It  was 
urged  that  as  iuttainnuition  was  attended  by  an  increase  of  heat,  swelling, 
and  redness,  such  remedies  should  be  employed  as  will  reduce  arterial 
tension.  Venesection  is  now  seldom,  if  ever,  resorted  to  in  the  treat- 
ment of  anj'^  form  of  inflammation.  An  unimpaired  ins  a  tergo  is  one  of 
the  best  means  to  prevent  stasis  within  the  inflamed  capillaries,  and 
practical  experience  has  shown  that  all  remedies  and  agents  which 
diminish  the  intra-arterial  tension  only  diminish  the  prospects  for  a 
favorable  termination  of  the  inflammation.  Cohnheim  showed  experi- 
mentally that  the  threatened  stasis  in  the  exposed  mesentery  of  the  frog 
was  avoided  by  injecting  into  one  of  the  veins  1  centimetre  of  a  6-per- 
cent, solution  of  sodic  chloride.  If,  under  similar  conditions,  a  consider- 
able quantity  of  blood  is  abstracted,  the  congestion  can  be  seen  to 
terminate  in  a  short  time  in  complete  stasis.  While  venesection  in  the 
treatment  of  inflammation  has  been  discarded,  the  direct  abstraction  of 
blood  from  the  inflamed  part  liss  proved  a  useful  therapeutic  resource. 
Genzmer  showed  that  in  the  inflamed  mucous  membrane  of  a  frog  scari- 
fication hastened  resolution.  In  order  to  be  of  benefit  the  scarification 
must  be  made  through  the  inflamed  part,  so  as  to  unload  directly  the 
dilated  and  engorged  capillary  vessels,  and  on  this  account  this  method 
of  treatment  is  only  applicable  when  the  inflammation  is  superficial  and 
affects  accessible  parts.  Leeches  should  never  be  used,  as  infection  from 
this  source  has  frequently  resulted  disastrously.  The  scarification  used 
for  cupping  is  difficult  to  keep  aseptic,  and  tlie  number  and  deptli  of  the 
scarifications  to  be  made  are  not  under  the  control  of  the  surgeon,  and 
for  these  reasons  this  instrument  has  only  an  historical  interest  and 
antiquarian  value.  The  scarification  should  be  made  with  a  sharp  scalpel, 
and  the  bleeding  encouraged  by  applying  warm  water.  Scarification  is 
followed  by  great  relief  in  inflammation  of  accessible  mucous  membranes, 
and  has  recentlv  been  very  strongl}'  recommended  in  the  treatment  of 
erysipelas  for  the  purpose  of  preventing  the  extension  of  this  disease. 


TREATMENT.  121 

In  the  different  forms  of  septic  inflammation  attended  by  severe 
general  S3'mptoms  the  gastro-intestinal  canal  often  participates  in  the 
process,  and  vomiting  and  diarrhoea  become  conspicuous  and  often  dis- 
tressing symptoms.  These  symptoms  should  not  be  checked,  as  they 
indicate  an  attempt  on  tlie  part  of  the  organism  to  eliminate  through  the 
gastro-intestinal  mucous  membrane  microbes  and  ptomaines  which  have 
reached  it  through  tlie  general  circulation.  The  sui-geon  should  assist 
this  effort  by  administering  a  few  doses  of  calomel,  followed  b}'  a  saline 
cathartic,  whicli  will  often  control  the  vomiting  and  diarrhoea  more 
promptl}'  by  removing  the  cause  than  medicines  employed  to  arrest  the 
process  of  elimination. 

Physiological  Rest. — One  of  the  most  urgent  indications  in  the  treat- 
ment of  inflamuuititm  is  to  secure  for  the  part  afi'ected  a  condition 
approacliing  physiological  rest.  In  ulcerative  affections  of  the  gastro- 
intestinal canal  the  patient  should  abstain  from  taking  food  b}'  the 
stomach.  Fixation  of  the  chest  by  means  of  broad  strips  of  adhesive 
plaster  affords  great,  relief  in  pleuritis.  An  inflamed  point  must  be  im- 
mobilized b}'  some  kind  of  a  splint.  A  chronic  c^^stitis  usually  j-ields 
to  supra-pubic  or  perineal  drainage  of  the  bladder  after  all  other  measures 
have  failed.  In  inflammatory-  affections  of  the  eye  exclusion  of  light  is 
one  of  tlie  most  essential  features  of  successful  treatment.  Patients 
suffering  from  inflammatory  affections  of  tlie  tonsils,  pharynx,  and 
larynx  should  use  their  voice  as  little  as  possible.  In  cases  of  acute 
inflammation  of  the  brain  or  its  envelopes  the  patients  must  be  kept  in  a 
dark  room,  and  absolute  quietude  enforced. 

Elevation  of  Inflamed  Part. — From  the  diminished  vis  a  tergo  on  the 
distal  side  of  the  capillaiy  vessels,  venous  engorgement  is  as  pronounced 
as  increased  arterial  tension  on  the  proximal  side  of  the  inflamed  capillary 
vessels,  and  elevation  of  the  inflamed  part  improves  the  vascular  dis- 
turbances b^'  the  force  of  gravitation  favoring  the  return  of  \tiious 
blood.  The  importance  of  elevation  of  the  inflamed  part  becomes 
manifest  in  the  treatment  of  inflammatory^  affections  of  the  extremities. 
In  phlegmonous  inflammation  of  the  hands  or  feet  the  throbbing  pain  is 
always  aggravated  if  the  limb  is  kept  in  a  dependent  position,  and 
promptly  relieved  npon  placing  it  in  an  elevated  position.  Elevation 
not  onl}'  alleviates  the  pain,  but  is  at  the  same  time  the  most  effective 
means  of  removing  tlie  oedematous  swelling.  If  necessary  elevation  can 
be  combined  with  suspension  in  order  to  secure  more  jjerfect  rest  for  the 
inflamed  part.  In  severe  acute  inflammation  it  is  not  only  necessary  to 
secure  rest  for  the  part  inflamed,  but  of  the  whole  body,  and  in  such 
cases  the  patient  must  observe  the  recumbent  position  in  bed,  as  all 
muscular  movements  and  all  unnecessarj-  strain  upon  the  blood-vessels 


122  PRINCIPLK8    OF    SURGERY. 

cannot  but  l)e  j)roductivo  of  harm  by  favoring  the  ingress  into  the  circu- 
lation of  micro-organisms  and  tlieir  ptomaines  from  the  seat  of  inflam- 
mation, or,  i)erliaps,  result  in  embolism  from  detachment  of  a  portion 
of  a  tlirombus, — an  accident  which  possibly  might  not  have  occurred 
otherwise. 

Application  of  Cold. — Cold  has  been  resorted  to  indiscriminately  and 
empirically  in  tiie  treatment  of  inflammation.  Cold  is  a  potent  agent  for 
good  or  harm,  according  to  the  stage  of  inflammation  during  which  it  is 
applied.  The  sensation  of  heat,  both  sul)jective  and  objective,  naturally 
suggested  the  use  of  this  remedy.  The  application  of  cold  is  of  great 
benefit  during  the  earliest  stage  of  inflammation,  at  a  time  when  exuda- 
tion is  only  beginning  and  the  capillary  vessels  are  dilated  and  only 
partially  obstructed.  Cold,  when  applied  under  these  circumstances, 
becomes  a  valuable  remedial  agent  (1)  by  producing  contraction  of  the 
small  blood-vessels  ;  (2)  by  producing  at  least  an  inhibitory  eftect  upon 
the  micro-organisms  in  the  inflamed  tissues.  The  contraction  of  blood- 
vessels which  takes  place  under  the  application  of  cold  has  a  tendency 
to  clear  the  capillaries  of  their  contents  and  to  prevent  further  mural 
implantation.  Micro-organisms  can  only  multiply  at  a  certain  tempera- 
ture, and  if  this  can  be  kept  at  a  point  low  enough  to  prevent  their  in- 
crease in  the  tissues  by  the  application  of  cold  this  agent  fulfills  one  of 
the  causal  indications  in  tlie  treatment  of  inflammation.  If,  however, 
stasis  has  already  taken  place  in  the  capillaries  first  affected  the  applica- 
tion of  cold  will  prove  harmful,  as  it  will  tend  to  prevent  the  formation 
of  an  adequate  collateral  circulation.  Cold  acts  most  beneficially  when 
the  inflammation  is  located  in  the  superficial  parts,  but  its  prolonged  use 
will  reach  even  deep-seated  structures,  as  the  pleura,  peritoneum,  the 
brain  and  its  envelopes,  the  joints  and  bones.  When  it  appears  desirable 
to  resort  to  the  use  of  cold,  this  remedy  should  be  applied  in  the  form 
of  an  ice-bag.  The  part  to  which  the  ice-bag  is  to  be  applied  can  be 
covered  with  several  la3^ers  of  a  wet  towel,  as  otherwise  the  prolonged 
use  of  the  direct  application  of  ice  may  freeze  the  skin.  The  sensations 
of  the  patient  can  actually  be  taken  as  a  safe  guide  as  to  the  length  of 
time  it  should  be  continued. 

Antiseptic  Fomentations. — The  ordinary  filthy  poultice  of  flaxseed, 
slippery  elm,  bread  and  milk,  has  no  longer  a  place  among  the  resources 
of  the  aseptic  surgeon.  The  common  poultice  is  a  hot-bed  for  bacteria, 
and,  as  such,  it  should  be  discarded.  In  the  treatment  of  an  ordinary- 
furuncle  with  poultices,  I  am  sure  that  almost  every  surgeon  must  have 
seen  occasionally  the  development  of  innumerable  minute  daughter- 
furuncles  in  the  surface  coA^ered  by  the  poultice.  In  phlegmonous  in- 
flammation of  the  fingers  or  hand  the  prolonged  use  of  the  poultice  is 


TREATMENT.  123 

followed  by  maceration  of  the  skin,  extensive  oedema  of  the  superficial 
structures,  a  flabby  condition  of  the  granulation, — in  fact,  all  the  evidences 
which  point  to  the  poultice  as  a  means  of  favoring  the  extension  of  the 
infective  process.  When  inflammation  has  passed  beyond  the  stage 
where  cold  exercises  a  favorable  influence,  or  where  cold  applications  in- 
crease the  suffering,  warm  aaitiseptic  fomentations  should  be  empIo3'ed. 
The  surface  to  which  the}'  are  to  be  applied  should  be  thoroughly 
cleansed  with  warm  water  and  potash  soap.  The  antiseptic  solution  to 
be  used  should  be  selected  according  to  the  age  of  the  patient,  or  the 
area  attected,  with  a  special  view  of  guarding  against  the  absorption  of 
a  toxic  dose  of  the  drug  employed.  Acetate  of  aluminum,  in  the 
strength  of  1  per  cent,  dissolved  in  sterilized  water,  is  a  safe  preparation 
under  all  circumstances.  Boracic  and  salicylic  acid  are  efficient  and 
safe  preparations.  Greater  care  is  necessary  in  the  use  of  carbolic  acid 
and  corrosive  sublimate,  as,  when  concentrated  solutions  of  these  drugs 
are  used  for  any  length  of  time  in  infants,  the  aged,  or  persons  suffering 
from  organic  disease  of  the  kidneys,  there  is  danger  of  poisoning  from 
absorption  through  the  intact  skin.  In  children  and  marantic  persons 
it  is  safer  to  use  acetate  of  aluminum,  salicylic  or  boracic  acid,  and  re- 
serve the  more  potent  antiseptics  for  adults  suffering  from  circumscribed 
inflammatory  lesions.  Hot  fomentations  act  as  derivatives  and  favor 
the  formation  of  collateral  circulation  ;  at  the  same  time  they  relieve  pain. 
A  number  of  layers  of  hygroscopic  gauze  or  flannel  cloth  are  wrung  out 
of  one  of  these  antiseptic  solutions  and  applied  over  the  affected  part, 
and  for  the  purpose  of  retaining  the  heat  and  of  preventing  evaporation 
of  the  solution  the  compress  is  to  be  covered  either  with  gutta-percha, 
rubber  sheeting,  or  macintosh  cloth,  and  the  dressing  is  retained  b}-  an 
appropriate  bandage.  The  compress  is  removed  two  or  three  times  a 
da}',  again  wrung  out  of  the  hot  solution,  and  re-applied  as  before. 
Absorption  through  the  skin  of  the  antiseptic  substance  used  ma}^  have 
a  direct  influence  in  diminishing  the  intensit^y  of  the  cause  which  pro- 
duced the  inflammation,  and  prepares,  in  an  admirable  manner,  the  field 
for  any  operation  which  ma}^  become  necessary  in  the  future. 

Antipyretics. — If  the  rise  in  temperature  which  attends  many  of  the 
acute  inflammatory  affections  is  due  to  the  introduction  into  the  circu- 
lation of  phlogistic  substances  which  are  produced  by  the  action  of  the 
micro-organisms  in  the  inflamed  tissues,  it  is  not  difficult  to  conceive  that 
its  artificial  reduction  by  the  internal  use  of  chemical  substances  is  not 
followed  by  any  permanent  benefit.  The  rational  treatment  of  the  fever 
consists  of  such  local  measures  as  will  remove  its  cause.  Antifebrin, 
antip3'rin,  salicylated  soda,  quinine,  and  other  antipyretic  drugs,  when 
employed  in  large  doses,  will    usually  reduce  the  temperature   several 


124  PRINCirLES   OF    SURGERY. 

degrees  for  a  lew  hours,  l)ut  this  is  always  accomplished  at  the  expense 
of  the  forces  which  are  laboring  to  clear  obstructed  paths,  and  on  this 
account  their  use  has  resulted  in  more  harm  than  good  to  the  patient. 
Quinine  is  the  least  objectionable  of  the  drugs  which  have  been  men- 
tioned, and  in  the  beginning  of  an  inflammation,  by  its  known  tonic  effect 
on  the  small  blood-vessels,  when  administered  in  a  large  dose,  has  a 
favorable  effect  in  preventing  rapid  dilatation  of  and  stasis  within  the 
ca[)illary  vessels.  If  used  at  all,  it  should  be  given  in  a  decided  dose, — 
1  gramme,  in  solution, — immediately  or  soon  after  tlie  development  of  the 
first  symptoms.  Sponging  the  surface  of  the  body  with  warm  water  or 
the  use  of  warm  baths  are  the  most  rational  antipyretics,  as  these  simple 
measures  do  not  weaken  the  heart's  action,  while  they  have  a  decided 
effect  on  the  temperature,  and  at  the  same  time  add  to  the  comfort  of  the 
patient  and  favor  the  elimination  of  microbes  through  the  excretory 
organs  of  the  skin.  As  the  kidneys  are  known  to  eliminate  micro- 
organisms that  reach  them  through  the  general  circulation,  their  func- 
tion should  be  carefully  inquired  into,  and  if  the  secretion  of  the  urine 
is  scanty,  diuretics,  like  liq.  amnion,  acet.,  or  acetate  of  potash  should 
be  given. 

Stimulants. — Just  as  soon  as  symptoms  of  sepsis  develop  in  the 
course  of  an  inflammation,  alcoholic  stimulants  should  be  freely  admin- 
istered to  meet  in  time  the  dangers  incident  to  heart-failure.  Stimulants 
have  largely  taken  the  place  of  antiphlogistics  at  the  present  time  in  the 
treatment  of  septic  inflammations.  Brandy,  cognac,  or  whisky,  not  in 
measured  doses,  but  given  in  quantities  large  enough  to  produce  the  de- 
sired effect  on  the  heart,  are  given  at  intervals  of  one  or  two  hours.  Cham- 
pagne is  a  more  diffusible  stimulant,  and  is  to  be  resorted  to  when  the 
stomach  does  not  tolerate  other  alcoholics.  In  chronic  cases,  Tokayer 
or  Greek  sherry  are  to  be  preferred.  In  wasting  diseases,  a  good  qualit}' 
of  beer,  ale,  or  porter  will  do  excellent  service.  In  cases  where,  from 
any  cause,  the  heart's  action  is  suddenly  diminished,  camphor  or  musk 
can  be  administered  subcutaneously  to  bridge  over  the  time  for  the 
employment  of  more  substantial  stimulants. 

Diet. — The  treatment  of  inflammation  by  starvation  has  been  abol- 
ished long  ago.  The  strength  of  the  patient  must  be  sustained  in  time 
by  a  nutritious,  well-selected  diet.  Animal  broths,  beef-tea,  and  milk 
should  be  freel}^  given  from  the  very  beginning,  and  if  more  substantial 
food  can  be  digested  it  should  not  be  withheld.  Oysters,  eggs,  fine- 
scraped  raw  meat,  or  rare  roast  are  excellent  articles  of  food  for  patients 
whose  strength  is  l)eing  undermined  by  debilitating,  suppurative  affec- 
tions. If  the  stomach  does  not  retain  food,  the  patient  should  be  nour- 
ished  by  rectal  enemata  of  peptonized  milk  and  beef-tea  in  quantities 


TREATMENT.  125 

not  exceeding  4  ounces,  given  alternatel}^,  every  eight  hours.  Ripe 
oranges  and  grapes  are  most  alwaj-s  grateful  to  the  patient,  and  theii' 
use  should  never  be  prohibited,  unless  the  gastro-intestinal  canal  is  the 
seat  of  inflammation. 

Tonics  and  Alteratives. — In  protracted  inflammatorj'  affections  ton'c 
doses  of  quinine  are  indicated.  Tincture  of  chloride  of  iron  is  an  excel- 
lent •  remedj^  after  the  acute  febrile  sj^'mptoms  have  subsided.  Under 
similar  circumstances,  one  or  more  of  the  bitter  tonics  can  be  given  with 
benefit  if  the  appetite  is  defective.  If  there  is  any  history  of  specific 
disease,  a  thorough  antisjphilitic  treatment  will  often  produce  a  marked 
effect  for  the  better  on  the  inflammatorj-  process.  Catarrhal  inflamma- 
tion in  rheumatic  patients  is  favorably  influenced  by  antirheumatic  rem- 
edies. Syphilitic  lesions  are  to  be  treated  b^-  potassic  iodide  and  small 
doses  of  corrosive  sublimate.  Tubercular  affections  call  for  arseniate  of 
iron,  sj-riip  of  iodide  of  iron,  and,  if  the  patient's  stomach  can  tolerate 
it,  pure  codliver-oil.  The  latter  drug  should  be  given  alone,  and  not 
in  emulsion,  in  gradualh-incrcasing  doses  an  hour  and  a  half  after  each 
meal. 

Anodynes. — Remedies  to  relieve  pain  must  alwa3'S  be  used  with 
caution,  as  in  painful  chronic  affections  their  prolonged  use  frequoitlv 
engender  a  habit.  The  cause  of  pain  must  be  sought  for,  and,  if  possible, 
removed  by  local  measures.  In  acute  inflammation,  pain  indicates  ten- 
sion in  the  inflamed  part,  and  prompt  relief  is  obtained  b^^  subcutaneous 
incision.  Periostitis  and  paronychia  should  be  treated  b}-  this  method. 
In  superficial  inflammations  scarification  answers  the  same  purpose.  If 
opiates  are  used,  a  decided  dose  is  better  than  smaller  doses  frequently 
repeated.  The  anodyne  effect  of  opium  is  increased  by  the  addition  of  a 
minute  dose  of  atropine.  Chloral  and  potassic  bromide  are  to  be  pre- 
ferred to  opium  to  relieve  the  pain  of  intra-cranial  lesions.  Phenacetine 
in  ^-gramme  doses  is  a  very  excellent  anodj'ue  in  cases  of  peripheral 
neuritis.  Inhalations  of  chloroform  to  allay  intense  pain  should  never  be 
resorted  to  except  by  the  direction  of  find  under  the  personal  supervision 
of  a  competent  phj'sician. 

Massage. — In  chronic  inflammator3'  affections  systematic  massage, 
scientificall}'  practiced,  is  an  exceedinglj-  important  and  valuable  thera- 
peutic resource.  It  stinnilates  the  surrounding  vessels  to  increased 
action,  and  exerts  a  potent  influence  in  restoring  the  normal  circulation 
in  the  affected  capillar}-  vessels,  and  alwa3S  promotes  absorption.  The 
mnsseur  should  be  instructed  to  apply  some  absorbent  preparation  before 
making  the  manipulations,  as  the  endermic  use  of  absorbent  drugs  in  this 
manner  will  increase  the  efficacy  of  the  treatment.  A  drachm  of  potassic 
iodide  or  half  a  drachm  of  iodoform  to  an  ounce  of  lanolin  will  be  an 


126  PKJNCIl'J.KS    OF    SUKGKllV. 

excellent  prepsiration  for  this  purpose.  Cold  and  hot  douches,  pussive 
and  active  motion,  combined  with  massage,  will  often  expedite  a  cure. 

Counter-Irritation. — Like  so  many  other  time-honored  methods  of 
treatment,  counter-irritation  in  the  treatment  of  acute  inflammation  has 
almost  entirely  gone  out  of  use.  In  chronic  inflammation,  ])listering  and 
painting  with  the  tincture  of  iodine  will  at  least  satisfy  tlie  patient,  if  no 
good  I'esult  from  them  ;  and  if  he  does  not  recover,  he  is  at  least  prevented 
from  passing  into  the  hands  of  charlatans  until  the  time  has  arrived  to 
resort  to  more  effective  and  radical  measures.  Kocher  praises  the  appli- 
cation of  the  actual  cautery  in  the  treatment  of  chronic  tubercular  osteo- 
myelitis and  synovitis.  The  seton  and  moxa  have  fallen  into  well- 
merited  disuse  for  all  time  to  come. 

Ignipuncture. — In  many  chronic  affections,  where  the  inflammatory 
exudation  remains  stationar}^  for  a  long  time,  multiple  punctures  with 
the  needle-point  of  a  Paquelin  cauter>',  made  under  strict  antiseptic  pre- 
cautions, will  have  a  prompt  effect  in  diminishing  the  primary  cause,  as 
well  as  in  promoting  absorption. 


CHAPTER  V. 

Pathogenic  Bacteria. 

Bacteria,  micro-organisms,  microbes,  and  germs  are  synonymous 
terms  for  certain  minute,  microscopical,  vegetable  organisms  wliicli, 
when  introduced  into  the  living  body,  produce  the  fever  and  the  tissue 
changes  described  in  the  preceding  chapter.  For  a  time  it  was  claimed 
that  these  minute  organisms  belonged  to  the  animal  kingdom,  as  some  of 
them  were  seen  to  possess  spontaneous  movements  ;  but  now  it  is  gener- 
ally agreed  that  they  are  minute  plants,  and  botanists  have  made  great 
progress  in  perfecting  a  scientific  classification.  Among  the  men  who 
have  developed  this  part  of  botau}',  the  names  of  Cohn,  Zopf,  and 
Nageli  stand  pre-eminent. 

CLASSIFICATION. 

The  pathogenic  bacteria  which  will  claim  our  attention  belong  to 
the  class  known  as  schizomycetes  (Spaltpilze).  In  diameter  they  vary 
from  0.001  to  0.004  millimetre,  and  are  composed  largely  of  an  albu- 
minoid substance  called  by  Nencki  mj^co-protein.  Toward  the  periphery 
this  substance  becomes  firmer,  and  forms  a  gelatinous  envelope,  a  sort  of 
a  membrane,  which  is  said  to  contain  cellulose,  and,  in  some  instances, 
even  fattj^  material.  The  outer  surface  of  bacteria  is  frequentl}'  cov- 
ered with  a  viscid  substance,  by  which  many  of  them  are  often  held 
together  in  a  mass  or  group,  technically  called  zoogloea.  Each  bacterium 
represents  a  cell,  although  the  presence  of  a  nucleus,  or  something  repre- 
senting such  a  structure,  has  not  been  demonstrated  ;  but  its  cellular 
structure  is  made  evident  b}'  its  intrinsic  power  of  germination  or  repro- 
duction when  surrounded  by  the  necessary  conditions  for  its  growth. 
Some  of  the  bacteria  are  })rovided  with  processes,  or  cilia,  by  which, 
when  suspended  in  a  fluid,  movements  are  accomplished  ;  in  others 
motion  is  entirely  deiiendent  on  molecular  movements  described  by 
BroAvn.  Niigeli,  and  formerly  Billroth,  claimed  that  all  bacteria  had  a 
common  botanical  source,  and  that  the  different  forms  and  actions  only 
represented  alteration  of  form  of  action  of  the  same  plant  at  different 
stages  of  development  and  under  different  circumstances, — in  other  words, 
that  a  coccus  could  be  transformed  into  a  bacillus,  and  vice  versa;  and 
that  in  one  instance  the  same  plant  caused  fermentation,  in  another 
putrefaction,  and  that  all  infective  diseases  were  caused   by  the  same 

(127) 


128 


PRINCIPLES    OP    SURGERY. 


microbe.     Buchner  maintained  tliat,  b}^  cultivation  in  different  nutrient 
media,  he  was  able  to  transform  the  dangerous  bacillus  of  anthrax  into 

A 

l5 


c 


r--\3 


.»•»    3 


••....- 


•; .  A 


••m.»«»"*% 


'••••••••«»^ 


••'53 


,M*»«>*'o 


/^ 


.y 


V.' 


h  \     1   I    . 


j^f^^'^^^^^^^^^Xr 


Fig.  43.— Different  Forms  of  Bacteria.    (Baumgarten.) 

A,  cocci  ;  B,  bacilli ;  C,  spirilli. 

the  harmless  bacillus   subtilis,  and,  again,  the  latter   into   the   former. 
Cultivation  and  inoculation  experiments  on  a  large  scale  by  most  careful 


MULTIPLICATION    OF    BACTERIA.  129 

observers  have  shown  conclusively  that  such  transformations  never  take 
place,  and  that  each  microbe  not  onl}'  always  retains  its  shape,  but  also 
its  specific  pathogenic  properties.  Pus-  and  other  microbes  have  been 
cultivated  through  thirty  and  more  generations  without  suffering  any 
morphological  deviations  or  losing  any  of  their  inherent  characteristic 
pathogenic  properties.  The  three  principal  forms  of  bacteria  discovered 
up  to  the  present  time,  and  which  have  been  demonstrated  as  causes  of 
disease,  are:  (1)  the  ball  (coccus);  (2)  rod  (bacillus);  (3)  corkscrew 
(spirillum).  As  illustrations  for  these  different  forms,  de  Bary  very 
appropriately^  takes  the  billiard-ball,  lead-pencil,  and  corkscrew. 

The  surgeon  has  to  deal  only  with  the  two  first  forms, — the  cocci 
and  bacilli.  Modifications  of  form  are  frequently  met  with,  as  an  oblong 
coccus  closeh'  resembles  a  short  bacillus,  and  a  short,  broad  bacillus  with 
rounded  ends  approaches  the  coccus  form.  Again,  a  double  coccus,  or 
diplococcus,  with  ill-defined  constriction  at  the  point  of  junction,  might, 
from  superficial  examination,  be  mistaken  for  a  bacillus  (Fig.  43,  A,  2). 
More  than  2  cocci  in  a  row,  or  a  chain  of  cocci,  are  called  a  streptococcus 
(A,  3).  Four  cocci  arranged  in  the  foi'm  of  a  square  are  called  a  micro- 
coccus tetragones  (A,  4).  Cocci  arranged  in  the  form  of  a  bunch  of 
grapes  are  called  streptococci  (A,  6).  An  iri'egular  mass  of  cocci,  when 
at  rest  and  held  together  bj-  a  viscid  substance,  is  described  as  a  zooglcea. 

MULTIPLICATION    OF   BACTERIA. 

Bacteria  multiply  with  great  rapidit}'  in  tissues  presenting  favorable 
conditions  for  their  growth,  or  in  proper  nutrient  media  kept  at  a  tempera- 
ture approaching  that  of  the  body.  Multiplication  takes  place  either  by 
fission  or  segmentation,  b}^  the  production  of  spores,  or  by  both  of  these 
methods.  The  bacillus  of  anthrax  multiplies  by  fission  in  the  bod}',  by 
spores  outside  of  the  bod}'. 

Fission. — The  round  or  globular  bacteria, — the  cocci, — as  far  as  we 
know,  multiply  only  by  fission.  The  cell  elongates  prior  to  segmenta- 
tion, when  a  constriction  appears  in  the  centre,  which,  b}'  becoming 
deeper  and  deeper,  finally  results  in  complete  division  of  the  cell  into 
two  equal  halves,  which  soon  attain  the  size  of  the  mother-cell,  and,  in 
turn,  again  undergo  the  same  process.  If  the  new  cells  remain  adherent, 
and  arrange  themselves  in  the  form  of  a  chain,  a  streptococcus  is  formed. 
Flugge  observed  complete  division  of  a  coccus  in  bouillon,  kept  at  a  tem- 
perature of  35°  C,  in  twenty  minutes.  If  it  should  require  one  hour  to 
complete  segmentation  and  for  the  new  cell  to  attain  maturity,  a  single 
coccus  multiplying  by  fission,  according  to  Cohn,  during  one  da}'^,  would 
produce  sixteen  millions  of  cocci,  and  at  the  end  of  the  second  day  the 
product  would  represent  two  hundred  and  eighty-one  billions  in  number, 


130 


PRINCIPLES   OF   SURGERY. 


0coqh, 


/ 


4r 


und  at  the  end  of  three  (htys  the  extraordinary  number  of  forty-seven 
trillions  would  be  reached.  Rod  bacteria  which  reproduce  themselves 
by  fission  undergo  transverse  segmentation  in  the  middle,  and  after  com- 
plete separation  each  segment  grows  to  the  size  of  the  parent-cell  before 
the  process  repeats  itSelf. 

Spores. — The  spores  of  bacteria  represent  the  seed  of  flowering 
plants.  Kacli  spore  develops  into  a  ])acterium,  and  thus  one  crop  after 
another  is  produced,  the  multiplication  increasing  with  the  number  of 
))actcria  in  the  soil.  Most  of  the  bacilli  multiply  by  spoi-es.  Fructifica- 
tion again  takes  place,  either  Avithin  the  ])r<jtoplasm  of  the  cell  (endospore) 
or  at  one  or  both  extremities  of  the  cell  (endsi)()re). 
Fructification  is  often  preceded  by  a  rapid  elonga- 
tion of  the  bacillus.  Multiple  endospores  usually 
form  in  one  bacillus  simultaneously.  The  first 
evidences  of  the  formation  of  spores  within  the 
]irotoplasm  of  a  bacillus  is  indicated  by  the  appear- 
ance of  circumscribed  points  of  cloudiness  at  equi- 
distant points. 

After  the  expiration  of  twenty  hours  the  bacil- 
lus appears  like  a  string  of  pearls,  each  segment  of 
which   represents  a  fully-developed  spore.      After 

\this  the  segments  separate  and  each  spore  develops 
into  a  bacillus. 
If  the  bacillus  reproduce  itself  by  a  single 
endospore,  it  does  not  elongate  before  fructification, 
but  increases  in  diameter,  especially  in  the  centre, 
so  that  it  assumes  the  shape  of  a  spindle  ;  while, 
equidistant  from  its  ends,  changes  are  observed  in 
the  protoplasm  which  indicate  the  beginning  of 
spore  formation.  If  the  bacillus  multiply  b}'  ter- 
minal fructification,  one  or  both  of  its  ends  enlarge, 
become  club-shaped,  and  the  spores  pass  through  the  same  stages  of 
development  as  the  endospores,  and  they  are  liberated  in  the  same  man- 
ner b}'  liquefaction  of  the  cell-membrane  surrounding  them.  Bacteriol- 
ogists are  familiar  with  the  fact  that  spores  possess  a  greater  power  of 
resistance  to  germicidal  agents  than  the  bacilli  which  produced  them. 
Mature  bacteria  are  always  destroyed  by  a  temperature  of  77°  C. ;  most 
of  them  succumb  when  exposed  to  a  heat  of  50°  to  55°  C.  On  the 
other  hand,  some  of  the  spores  are  known  to  survive  a  temperature  of 
100°  to  120°  C. 

Sternberg  has  determined  the  thermal  death-point  of  the  following 
bacteria : — 


8 


Fig.  44.— Endogenous 
Spore  Produc- 
tion IN  Bacii.lus 
Anthracis  Cui/n- 
VATED  upon  Meat- 
Infusion  Peptone- 
Gelatin.  X  950. 
(Baumgarten.) 


CULTIVATION    OF    BACTERIA.  131 

Fahr. 

Bacillus  anthracis  (Chaveau), 129.20° 

Bacillus-aiithracis  spores, 212. 0° 

Bacillus  tuberculosis  (Schill  and  Hischer),  ....  212.0° 

Staphylococcus  albus, 143.6° 

Staphylococcus  pyogenes  aureus,  .......  136.4° 

Staphylococcus  pyogenes  citreus, 143.6° 

Streptococcus  erysipelatosus, 129.2° 

Gonococcus, 140.0° 

In  all  experiments,  with  the  exception  of  the  hacilliis  of  tubercnlosis, 

the  microbe  was  suhjected  to  the  specified  heat  for  ten  minutes;  the 

tubercle  bacillus  was  destroyed  in  four  minutes.     Such  resisting  spores 

are  often  not  destroyed  by  boiling  continued  for  several  minutes,  and 

yield   onl}-   slowly  and   frequently   imperfectly   to   germicidal    chemical 

agents.     Surgeons  are   aware  that  such  spores  maj-  re-  g 

main  dormant  in  the  bod}'  for  years  without  giving  rise  iiP 

to  any  symptoms   until  aroused  to  activit}'  by  surround-  i  2  3 

ing  conditions  favorable  to  their  growth  and  development,     fig.   45.— Spore 

OF   Bacillus 
OF  Anthrax. 

CULTIVATION    OF    BACTERIA.  sJ-yf'     ''^^ 

The   first  cultivation   experiments  were  made   with     fore'kermiuation;  1, 

2,  3,  three   successive 

fluid    nutrient    substances,    such    as    bouillon,    different     etaftes  of  germinating 

'  '  spore ;  6,  young  rod. 

animal  broths,  and  solutions  of  sugar.  Koch  introduced 
solid  nutrient  media,  which  not  onl}^  serve  as  food  for  the  bacteria,  but 
at  the  same  time  present  the  great  advantage  that  the  colonies  can  be 
seen  with  the  naked  eye,  and  their  microscopical  appeai-ances,  as  well 
as  the  visible  action  of  the  bacteria  on  the  nutrient  substance,  often  are 
sufficient  to  conve}^  reliable  information  to  enable  the  observer  to  form  a 
positive  conclusion  in  reference  to  the  kind  of  microbes  of  which  the 
colonies  are  composed.  In  fluid  nutrient  media  the  bacteria  cause  tur- 
bidit}',  or  they  appear  as  a  thin  film  on  the  surface ;  or  zoogloea  masses 
show  themselves  as  swimmiijg  flocculi ;  or,  finally,  when  the  fluid  has 
been  exhausted  of  its  nutrient  supply  the  spores  settle  at  the  bottom  of 
the  vessel  and  appear  as  a  pulvurulent  deposit.  Upon  solid  nutrient 
media  each  kind  of  bacteria  appear  as  isolated,  distinct  colonies,  and  as 
such  can  be  recognized  by  the  naked-e3^e  appearances. 

The  substance  used  first  by  Koch  as  a  solid  medium,  and  which  is 
now  used  more  than  any  other,  was  gelatin.  Later,  a  jelly-like 
substance  called  agar-agar,  obtained  from  several  sea-weeds  on  the  coasts 
of  Japan  and  India,  Avas  found  superior  to  gelatin  where  a  higher  than 
ordinar}'  temperature  was  required  to  cultivate  certain  microbes. 
Edington  prefers  a  gelatin  made  of  Irish  moss  to  agar-agar,  as  it  is 
more  transparent.  Some  microbes  that  will  not  grow  upon  gelatin 
vegetate  luxuriantly  on  solid  blood-serum.     The  tubercle  bacillus  grows 


132 


PRINCIPLES    OF    SURGERY. 


equally  well  upon  solid  blood-serum  and  glycerin  agar-agar.  This  latter 
substance  is  easily  prepared  and  is  made  by  adding  6  per  cent,  of  pure 
glycerin  to  the  ordinary'  agar  medium. 

The  busy  practitioner,  who  has  no  time  to  prepare  the  media  used  in 
laboratory  work,  can  do  good  bacteriological  work  by  using  sterilized 
potato  or  bread-paste.  The  potato  is  the  best  medinm  for  the  cultiva- 
tion of  chromogenous  bacteria,  or  such  as  secrete  a  coloring  matter,  as 
upon  this  substance  the  color  is  preserved.  The  potato  is  scrubbed  with 
a  hard  brush  under  a  stream  of  water.  It  is  then  left  in  a  solution  of 
corrosive  sublimate  (1  to  1000)  for  an  hour  or  so  to  disinfect  its  surface. 
With  a  knife  rendered  sterile   by   passing  it  through  the  flame  of  a 


'/Jv 


Fig.  46.— Gelatin  Cultures  following  Surface  Inoculation.    (Fliigge.) 

Bunsen  lamp,  a  quadrilateral  piece  is  cut  from  the  centre,  and  is  rapidly 
transferred  on  the  knife  to  a  glass  capsule  previously  sterilized  by  heat. 
Capsule  and  potato  are  next  placed  in  steam  sterilizer,  when  the  simple 
apparatus  is  ready  for  inoculation.  Inoculation  is  done  b}'  charging  the 
point  of  an  aseptic  needle  with  the  culture,  or  substance  containing  the 
microbes,  and  after  lifting  the  capsule  half  up  a  number  of  streaks  are 
made  with  the  needle  upon  the  surface  of  the  potato.  A  potato-paste, 
made  by  adding  a  sufficient  quantit}^  of  distilled  water  to  the  interior 
portion  of  boiled  potatoes  to  make  a  paste,  is  used  in  the  same  manner 
and  answers  the  same  purpose  as  sterilized  raw  potato. 

Bread-paste  is  made  of  stale,  coarse  bread,  thoroughly  dried  in  an 
oven,  but  not  roasted.     It  is  pulverized  in  a  clean  mortar  and  the  powder 


CULT1VATIU^■    OF    BACTERIA. 


133 


made  into  a  paste  by  adding  distilled  water.  The  paste  is  transferred  to 
sterile  glass  capsules  and  used  in  the  same  manner  as  potato-paste.  If 
it  is  employed  for  the  culture  of  bacteria,  it  must  \)e  neutralized  with  a 
solution  of  carbonate  of  soda.  Some  microbes  possess  the  facult}'  of 
liquefying  the  gelatin ;  others  remain  as  solid  cultures  upon  the  surface 
of  the  medium,  or  in  its  interior.  Free  access  of  oxygen  to  the  seat  of 
inoculation  is  essential  for  the  growth  of  some  microbes,  and  these  Avere 
termed  b}'  Pasteur  aerobiontic,  while  those  that  germinate  with  exclusion 
of  oxygen  he  culled  anaerohiontic.  The  former  class  germinate  on  the 
surface  of  the  media  with  or  without  liquefaction  of  the  soil.  If  microbes 
of  this  kind  are  inoculated  by  scratching  the  surface  of  the  medium  with 


Fig.  47.— CrLxrRES  in  Gelatin  growing  in  the  Track  made  by  the 
Needle.     (Fli'igge.) 


the  point  of  a  needle  charged  with  tliem,  the  culture  appears  first  at 
isolated  points  (Fig.  46,  A),  which  hy  increase  in  size  become  confluent 
and  occupy  as  a  solid  mass  the  whole  track  made  by  the  needle  (B,  C). 

In  making  inoculations  with  anaerobiontic  bacteria  the  gelatin  is 
punctured  with  a  needle,  charged  as  before,  to  some  depth,  and  isolated 
colonies  appear  in  tlie  track  made  b}-  the  needle,  which  hy  confluence 
form  a  continuous,  uninterrupted  culture  the  whole  depth  of  the  needle, 
which  increases  in  diameter  by  extension  in  a  peripheral  direction. 
Superficial  cultures  are  called  streak  cultures ;  deep  cultures,  stab 
cultures. 

All  cultivation  experiments  must,  of  course,  be  conducted  under 
strictest  antiseptic   precautious,  as  otherwise  there  is  great  danger  of 


134  PRINCIPLES   OF    SURGERY. 

contamination  of  the  cultures  by  the  accidental  ingress  of  other  microbes, 
especially  of  some  forms  of  fungi. 

ESSENTIAL    CONDITION    FOR   GROWTH    OF   BACTERIA. 

For  the  germination  of  bacteria,  besides  a  proper  nutrient  substance 
the  other  conditions  which  enable  the  growth  of  other  plants  from  seed 
are  necessary,  viz.,  moisture  and  a  certain  degree  of  heat.  Inspissation 
of  solid  nutrient  medium  arrests  further  development  of  a  culture. 
Bacteria  cannot  grow  npon  a  perfectly  dry  medium.  Most  microbes 
germinate  best  at  a  temperature  corresponding  to  blood-heat,  but  in  this 
respect  the  different  kinds  show  great  variance,  as  some  vegetate  at 
10°  C,  while  the  growth  of  others  will  continue  at  65°  C.  Acids  appear 
to  produce  an  inhibitory  effect  on  the  process  of  germination. .  Laplace 
has  utilized  this  fact  and  advises  the  addition  of  citric  acid  to  solutions 
of  corrosive  sublimate  to  intensify  its  germicidal  properties.  It  is  well 
known  that  the  gastric  juice  suspends  the  growth  of  most  bacteria. 
Bacteria  which  live  on  dead  substances  exclusivel}^  are  called  sapro- 
phytes. Bacteria  which  feed  on  dead  substances  and  can  exist  in  the 
living  tissues  only  at  a  certain  stage  of  development  are  called  facultative 
parasites,  in  comparison  with  the  obligatory  parasites,  which  multiply 
exclusively  in  the  living  tissues.  As  representatives  of  the  former  can 
be  enumerated  the  bacillus  of  anthrax  and  cholera,  which,  under  favor- 
able conditions,  can  multipl}^  outside  of  the  body,  while  the  bacillus  of 
tuberculosis  germinates  only  in  the  living  body. 

ACTION    OF   BACTERIA   ON    TISSUES    OF   THE  BODY. 

The  action  of  pathogenic  bacteria  on  the  tissues  is  a  twofold  one. 
In  the  first  place,  they  abstract  from  the  bod}"  a  part  of  its  essential 
constituents ;  for  example,  albuminous  substances,  carbohj'^drates,  oxy- 
gen, etc.  These  substances  are  not  only  taken  from  the  fluids  of  the 
body,  as  the  blood  and  13'mph,  but  also  directly  from  the  protoplasm  of 
the  cells.  In  the  second  place,  they  produce  in  the  body  toxic  agents 
from  their  action  on  the  albuminoid  substances.  The  decomposition  of 
albuminoid  substances  by  the  action  of  bacteria  results  in  the  formation 
of  ammonia  and  its  derivatives,  the  different  amines,  CO2,  HgS,  indol, 
scatol,  phenol,  asparagin,  leucin,  tyrosine,  etc. 

Ptomaines. — The  common  name  for  the  toxic  substances  of  bacterial 
origin  is  ptomaines.  Brieger  has  isolated  a  number  of  ptomaines  from 
cultures  of  different  bacteria,  and  Hoffa  is  now  engaged  in  the  same 
kind  of  work.  Yaughn,  of  this  country,  has  written  a  valuable  work  on 
this  subject,  which  should  be  read  b}-  all  who  wish  to  become  familiar 
with  modern  surgical  pathology.     Brieger  has  isolated  a  number  of  toxic 


INOCULATION    EXPERIMENTS.  135 

alkaloids,  cadaverin,  neuriu,  muscarin,and  inydalein,  which  are  intensely' 
toxic,  while  the  derivatives  of  ammonia-dimethylainin,  trimeth^damin, 
and  triath3darQin  are  much  less  dangerous  substances.  The  ptomaines, 
being  soluble  substances,  are  readily  absorbed,  and  ^Yhen  introduced  into 
the  circulation  produce  fever  and  symptoms  of  sepsis.  The  ptomaines 
of  the  bacillus  of  tetanus  act  principally  upon  the  central  nervous  S3's- 
tem,  producing  characteristic  tonic  and  clonic  spasms  of  definite  groups 
of  muscles.  The  ptomaines  also  produce  a  definite  local  effect, — thus, 
tiie  ptomaines  of  pus-microbes  transform  the  leucoc3'tes  and  embryonal 
cells  into  pus-corpuscles,  those  of  the  microbe  of  progressive  gangrene 
destroy  the  protoplasm  of  the  cell-bod}^  (lirectlj^,  while  the  toxic  sub- 
stances of  the  microbes  of  chronic  infective  diseases  transform  the  fixed 
tissue-cells  into  embryonal  or  granulation  cells.  Some  of  the  microbes 
remain  in  the  tissue  at  the  seat  of  infection  ;  others  localize  in  tlie 
lymphatic  channels,  while,  finall}',  others  enter  the  general  circulation 
and  multipl}'  in  distant  organs.  The  production  of  ptomaines  usually 
takes  place  in  the  tissues  in  which  localization  takes  place. 

INOCULATION    EXPERIMENTS. 

The  mouse,  rat,  rabbit,  guinea-pig,  and  dog  are  the  animals  usually 
selected  for  this  purpose.  Inoculations  are  made  either  Avitli  pure  cul- 
tures, which  are  injected  b}'  means  of  a  sterilized  hypodermatic  sj-ringe, 
or  infected  tissues  are  implanted  under  strict  antiseptic  precautions. 
Injections  of  pure  cultures  are  made  either  into  the  subcutaneous  tissue 
or  one  of  the  large  serous  cavities,  the  pleural  or  peritoneal  cavit}'.  The 
same  localities  are  generall}^  selected  for  inoculation  by  means  of  im- 
plantation of  infected  tissue.  For  instance,  granulation  tissue  from 
tubercular  lesions  is  either  introduced  into  a  small  pocket  made  in  the 
subcutaneous  tissue  in  the  inguinal  region  of  a  guinea-pig,  or  a  small 
fragment  is  inserted  into  the  pleural  or  peritoneal  cavity  through  a  small 
incision.  Before  the  incision  is  made  it  is  absolutely  necessary  to  shave 
the  surface  and  disinfect  it  in  the  usual  way.  After  the  implantation  is 
made  the  Avound  is  closed  by  suturing  with  fine  catgut,  after  which  it  is 
sealed  witli  collodium.  In  the  course  of  two  or  three  weeks  the  subcu- 
taneous graft  has  become  the  centre  of  a  local  tubercular  focus,  whicli 
soon  gives  rise  to  regional  infection  through  the  lymphatic  vessels,  to  be 
followed  at  the  end  of  five  or  six  weeks  by  general  diffuse  miliary  tuber- 
culosis. In  cases  where  it  is  impossible  to  make  a  ditferential  diagnosis 
between  a  sypliilitic  and  tubercular  lesion,  inoculation  of  a  guinea-pig 
with  a  fragment  of  the  granulation  tissue  will  furnish  positive  informa- 
tion in  the  course  of  a  few  weeks.  If  the  lesion  is  syphilitic,  the  result 
of  the  inoculation   will  be  negative;   if  it  is  tubercular,  local,  regional, 


136  PRINCIPLES   OF    SURGERY. 

and  general  infection  will  follow  in  regular  order.  In  making  implanta- 
tion experiments  from  animal  to  animal,  it  is  necessary  to  remove  the 
graft  immediatel}',  or  soon  after  death,  and  to  resort  to  the  necessary 
precautions  to  prevent  contamination  during  its  conveyance  from  the 
dead  to  the  living  animal.  In  bacterial  diseases  which  affect  the  l)lood, 
inoculation  can  be  practiced  by  injecting  blood,  abstracted  from  the  in- 
fected animal,  into  the  subcutaneous  tissue  or  gener:il  circulation  of  a 
healthy  animal,  with  the  effect  of  reproducing  the  disease.  Anthrax 
and  septiciemia  of  mice  furnish  good  illustrations  of  this  class  of 
diseases. 

ATTENUATION    OF    PATHOGENIC   BACTERIA. 

Pasteur  opened  a  wide  field  for  investigation  in  preventive  medicine 
by  his  introduction  of  prophylactic  inoculations.  He  experimented  first 
with  the  microbe  of  chicken-cholera  and  the  bacillus  of  anthrax.  The 
microbe  of  fowl-cholera  was  cultivated  in  chicken-bouillon  for  three, 
four,  five,  or  eight  months.  He  found  that  by  this  time  the  virus 
becomes  so  attenuated  that,  when  injected  into  a  healthy  chicken,  it  kills 
only  in  exceptional  cases.  Experience  showed  that  attenuation  onlj- 
occurred  when  the  culture  is  freely  exposed  to  atmospheric  air,  and 
therefore  Pasteur  believed  that  the  prolonged  contact  of  the  culture 
with  oxygen  diminished  its  virulence.  Chickens  inoculated  with  weak 
cultures  were  rendered  immune  to  the  action  of  the  active  virus.  The 
same  author  made  the  discovery  that  the  anthrax  bacillus,  cultivated  in 
the  same  way  at  a  temperature  ranging  between  40°  and  43°  C,  loses  its 
virulence  gradually,  so  that  on  the  ninth  da}'  it  is  rendei'ed  harmless. 
Inoculation  with  attenuated  cultures  protected  sheep  against  the  active 
virus.  Koch,  Gaffky,  and  Loeflfler  found  that  a  culture  of  anthrax  bacilli 
twenty  days  old,  attenuated  at  a  temperature  of  42°  to  46°  C,  was  still 
sufficiently  strong  to  kill  mice,  but  had  little  effect  on  guinea-pigs  and 
sheep.  A  culture  twelve  days  old  killed  guinea-pigs,  but  not  sheep.  It 
proves  fatal  to  sheep  up  to  six  days  of  cultivation.  Their  views  in 
reference  to  the  cause  of  attenuation  differ  from  Pasteur's,  who  regards 
oxygen  as  the  active  agent,  while  these  observers  attribute  it  exclusivel}' 
to  the  high  temperature.  The}'  succeeded,  like  Pasteur,  by  using  attenu- 
ated cultures  in  protecting,  in  most  cases,  sheep  against  the  action  of 
virulent  cultures.  In  his  practical  work  Pasteur  uses  two  strengths  of 
mitigated  virus.  The  milder  vaccine  is  a  culture  fifteen  to  twenty  days 
old  ;  the  stronger  vaccine  is  from  ten  to  twelve  days  old.  Sheep  are 
inoculated  first  with  the  milder  vaccine,  and  after  an  interval  of  twelve 
to  fifteen  days  the  stronger  culture  is  used.  Animals  thus  treated  are 
either  entirely  immune  to  anthrax,  or,  if  they  contract  the  disease,  it 
assumes  a  mild  type.     Other  methods  of  attenuation  of  active  cultures 


THERAPEUTIC  INOCULATION.         *      137 

to  be  used  for  prophylactic  inoculations  have  been  devised,  l)iit,  as  tliev 
appear  to  have  been  put  only  to  a  limited  extent  to  practical  tests,  they 
will  be  onh'  briefl}-  mentioned  here.  Sanderson  found  that  the  bacillus 
of  anthrax  loses  much  of  its  virulence  when  passed  through  the  system 
of  a  guinea-pig.  Toussaint  and  Chaveau  found  that  tiie  action  of  a 
temperature  of  from  50°  to  55°  C,  continued  for  five  to  twenty  minutes, 
greatly  diminishes  the  virulence  of  the  bacillus  of  anthrax.  For  the 
attenuation  of  spores  a  temperature  of  80°  C.  is  required. 

Paul  Bert  showed  that  oxygen,  under  a  pressure  of  from  20  to  40 
centimetres,  destroys  the  bacillus  of  anthrax.  Toussaint,  Chamberland 
and  Roux,  and  Klein  made  experiments  to  determine  the  influence  of 
chemical  agents  in  effecting  attenuation  of  active  cultures,  and  their 
work  has  shown  that  the  virulence  of  some  bacteria  can  be  greath^ 
diminished  and  even  entirely  suspended  b^^  this  method  of  treatment. 
Arloing  asserts  that  anthrax  bacilli,  exposed  to  a  bright  sunlight  in  a 
liquid  medium,  graduall}-  part  with  their  toxic  qualities.  More  accurate 
knowledge  and  greater  experience  in  this  interesting  field  of  prophylactic 
inoculations  will  undoubted!}-  lead  to  important  results  in  the  near 
future. 

THERAPEUTIC  INOCULATION. 

Therapeutic  inoculations  have  been  put  to  a  practical  test  upon  a 
knowledge  obtained  from  laboratory  work,  that  direct  antagonism  exists 
among  certain  kinds  of  micro-organisms.  Emmerich's  experiments  on 
rabbits  have  demonstrated  the  value  of  the  streptococcus  of  erj-sipelas 
as  a  protective  and  curative  agent  in  anthrax  in  these  animals.  In  one 
series  of  experiments  the  rabbits  were  first  inoculated  with  a  large 
quantity  of  a  reliable  culture  of  the  microbe  of  erysipelas,  and  then,  two 
to  fourteen  days  later,  the  animals  were  infected  with  a  pure  culture  of 
the  anthrax  bacillus.  Of  15  animals  treated  in  this  way,  7  recovered, 
while  all  the  control  animals  inoculated  only  with  anthrax  died  ;  of  the 
7  animals  which  died  after  double  infection,  some  succumbed  to  the 
anthrax  bacillus  and  some  to  the  .streptococcus  of  erysipelas.  Thera- 
peutic inoculations  with  cultures  of  the  microbe  of  er^'sipelas  in  animals 
suffering  from  anthrax  were  less  successful.  Garre  has  studied  ant;ig- 
onism  among  bacteria  on  culture  soils.  He  made  many  careful  experi- 
ments to  determine  the  growth  of  a  culture  on  different  nutrient  media, 
by  removal  of  the  entire  culture  with  a  minute  spade  and  inoculation 
of  the  same  soil  with  another  microbe.  From  the  results  obtained 
thus  far  he  has  ascertained  that  some  microbes  affect  the  soil  favorably-  for 
the  growth  of  other  varieties,  while  others  render  it  sterile.  For  example, 
a  culture  medium  impregnated  with  the  ptomaines  of  the  bacillus 
fluorescens  putidus  remains  perfectl}'  sterile  when  inoculated  with  pus- 


138  PRINCIPLES   OF    SURGERY. 

microbes.  These  investigations  liave  an  important  practical  bearing,  as 
future  research  may  not  only  show  the  way  to  secure  immunity  from  in- 
fection by  pathogenic  microbes  by  prophylactic  inoculations  with  harm- 
less microbes,  but  may  likewise  establish  a  system  of  rational  and 
effective  treatment  by  inoculations  of  cultures  of  antagonistic  bacteria 
for  therapeutic  purposes.  Therapeutic  inoculations  with  potent  cultures 
have  also  been  made  with  some  success  in  the  treatment  of  inoperable 
malignant  tumors.  In  a  recent  publication  on  this  subject  Bruns  gives 
the  result  of  22  cases  of  malignant  growths,  including  1  that  came  under 
his  own  observation  that  passed  through  an  attack  of  erysipelas.  Bruns's 
case  was  one  of  melanosarcoma  of  the  breast,  in  which  a  final  cure 
followed  the  attack.  Out  of  5  sarcomata,  3  were  permanentl}^  cured, 
while  the  other  2  were  diminished  in  size,  but  soon  returned  to  their 
former  size.  The  effect  of  the  erysipelatous  invasion  proved  negative 
in  6  cases,  in  which  the  diagnosis  between  carcinoma  and  sarcoma  could 
not  be  positively  made,  as  also  in  3  cases  of  ulcerative  epithelioma.  It 
is  stated  that  in  cicatricial  keloid  and  Ij'mphomata  the  attack  of  erysipelas 
proved  curative. 

BACTERIA    OUTSIDE    OF    THE    BODY. 

Bacteriology  has  rendered  the  term  miasma  obsolete.  All  infective 
diseases  are  now  traced  to  an  organic  contagium.  Most  of  the  bacteria 
are  ectogenous ;  that  is,  they  exist,  and,  under  favorable  circumstances, 
multiply  outside  of  the  bod}-.  The  microbe  of  syphilis,  in  all  probability, 
is  an  endogenous  parasite.  Auto-infection  is  a  misapplied  term,  as  nearly 
all,  if  not  all,  infective  diseases  are  caused  by  the  introduction  into  the 
body  of  pathogenic  bacteria  from  without.  Some  microbes  exist  in  the 
soil,  and  as  they  or  their  spores  may  exist  in  an  active  condition  for  an 
indefinite  period  of  time,  or  even  germinate  there,  they  give  rise  to 
endemics  of  infective  diseases.  The  anthrax  bacillus,  the  bacillus  of 
tetanus,  and  the  actinomyces  can  be  included  in  this  categor3\  Other 
microbes  are  diffused  over  large  territories  through  water-courses,  as  the 
bacillus  of  typhoid  fever  and  cholera.  Finally,  some  bacteria,  like  pus- 
microbes,  appear  to  be  ubiquitous,  being  present  everywhere  and  at  all 
times.  Of  all  substances  which  serve  as  a  carrier  of  microbes,  the 
atmospheric  air  is  the  most  important,  because  it  is  present  everj^where 
on  the  surface  of  the  globe,  and  no  one  can  exclude  himself  from  it.  In 
a  dry  state,  pathogenic  bacteria  move  with  the  currents  of  air  and  attach 
themselves  again  to  the  solid  or  fluid  substances  with  which  they  come 
in  contact.  Although  most  of  the  pathogenic  bacteria  under  ordinary 
circumstances  do  not  reproduce  themselves  outside  the  body,  their 
resistance  to  heat  and  cold,  moisture  and  dr3'ness,  is  so  great  that  they 
retain  their  disease-producing  qualities  often  for  an  indefinite  period  of 


PRESENCE   OF   PATHOGENIC    BACTERIA  IN    THE    HEALTHY  BODY.       139 

time,  and  after  their  entrance  into  the  bod}^,  and  meeting  with  a  proper 
nutrient  medium,  they  exert  their  specific  pathogenic  effects.  From  a 
practical  stand-point  it  is  important  to  remember  that  infection  takes  place 
by  the  entrance  into  the  tissues  or  body  of  micro-organisms  from  without^ 
through  some  defect  of  the  skin  or  mucous  membranes,  hence  by  contact 
entrance  of  bacteria  into  the  body.  As  a  rule,  to  which  there  are  few 
exceptions,  bacteria  ai-e  introduced  into  the  body  through  a  wound, 
abrasion,  or  ulceration  of  the  skin  or  a  mucous  membrane.  Such  a 
defect  or  gateway  is  called  an  infection-atrium.  A  healthy,  granulating 
surface  furnislies  almost  as  secure  a  protection  against  infection  as  the 
skin,  but  when  the  granulations  are  destroyed  or  injured  infection  is 
again  liable  to  occur.  On  this  account  probing  of  a  fistulous  canal  has 
not  infrequently'  resulted  in  aggravation  of  the  local  symptoms,  and 
even  in  general  infection.  Kiister  reports  2  cases  where  patients  who 
had  undergone  an  operation  for  hydrocele  by  incision,  and  who  were 
permitted  to  leave  the  hospital  before  the  wound  had  completely  healed, 
died  subsequently-  from  sepsis  caused  by  careless  after-treatment  of  tlie 
granulating  surface.  Most  of  the  microbes,  after  they  have  become 
deposited  upon  an  absorbing  surface,  exercise  first  their  pathogenic 
qualities  at  the  seat  of  primary  localization.  The  action  of  some  of 
them  always  remains  local.  If  the  infection  spread,  it  does  so  by  dis- 
semination of  the  microbes  over  a  surface,  along  the  connective  tissue, 
or  through  the  lymphatics  or  blood-vessels.  There  is  no  reason  to  doubt 
that  bacteria  can  gain  entrance  into  the  tissues  and  the  circulation  by 
passing  through  intact  mucous  membranes  in  the  same  manner  as  minute 
particles  of  inorganic  material,  like  coal-,  marble-,  and  ivory-  dust.  This 
brings  up  the  question  of  the 

PRESENCE    OF    PATHOGENIC    BACTERIA    IN    THE    HEALTHY    BODY. 

It  still  remains  a  disputed  question  whether  pathogenic  micro- 
organisms can  exist  in  the  body  without  giving  rise  to  disease.  It  has 
been  definitel}'  ascertained,  by  experimental  research,  that  man}'  of  the 
jiathogenic  microbes  are  harmless  as  long  as  they  remain  in  the  circu- 
lating blood,  and  that  their  specific  pathogenic  action  only  becomes 
evident  after  localization  has  taken  place  in  some  part  of  the  body,  in  a 
soil  prepared  ]\y  injury  or  disease  for  their  reproduction.  It  has  also 
been  conclusive!}'  sliown,  by  clinical  experience,  that  pathogenic  spores 
may  remain  in  the  Iiealthy  body,  in  a  dormant  condition,  for  an  indefi- 
nite period  of  time,  until,  by  some  accidental  pathological  changes,  the 
tissues  in  which  the}'  may  exist  have  been  prepared  for  their  germina- 
tion. Numerous  experiments  will  be  cited  elsewhere,  in  which  injections 
of  pure  cultures  directly  into  the  circulation  produced  no  ill  effects  in 


140  PRINCIPLES   OF    SURGERY. 

healthy  animals,  but  when  previous  to  the  injection, or  soon  after,  an  injury 
was  inllicted  in  some  part  of  the  body,  localization  occurred  at  tlie  seat  of 
trauma,  ami  in  the  locus  minoris  resistentiee  thus  created  the  microbes  pro- 
duced their  specific  pathogenic  effects.  From  these  remarks  it  is  reason- 
able to  assume  that  j)athogenic  microbes  may  and  do  exist  in  the  healthy 
body  without  necessarily  giving  rise  to  disease,  esjiecially  if,  as  is  well 
known,  they  are  being  constantly  eliminated  through  the  excretory  organs. 
Bizzozero  could  not  detect  bacteria  of  an}'  kind  in  animals  soon  after 
birth,  but  in  tlie  lymph-follicles  of  the  caecum  in  healthy  rabbits  he  found 
numerous  micro-organisms.  They  were  seen  mostly  in  the  protoplasm 
of  cells, — a  condition  which  would  indicate  that  they  are  transferred  from 
the  intestinal  canal  into  the  closed  lymph-follicle  through  the  medium  of 
migrating  cells.  In  the  human  subject,  Kibbert  found  micro-organisms 
in  the  interior  of  the  epitlielia  lining  the  intestinal  canal,  but  thej'  were 
absent  in  the  submucosa.  Perhaps  the  epithelial  cells  in  this  locality 
take  the  part  of  piiagocytes.  Zahor  examined  the  blood,  testicle,  heart, 
and  spleen  of  a  health}'  rabbit,  and  found  in  fresh  as  well  as  in  hardened 
sections,  after  staining  with  methyl-violet,  cocci,  and  here  and  there  rods. 
The  same  examinations,  with  like  results,  were  made  on  the  organs  of  a 
young  eat.  Fodor  introduced  directly  into  the  circulation  of  rabbits 
pathogenic  bacteria,  in  order  to  study  their  effects  on  the  tissues  and 
manner  of  elimination.  As  a  rule,  he  found  the}'  had  completely  disap- 
peared from  the  blood  after  twenty-four  hours.  He  believes  that  the 
bacteria  are  destroyed  in  the  circulation  by  the  blood-corpuscles.  The 
same  author  maintains  that  the  power  of  the  blood  to  destroy  bacteria 
is  not  diminished  by  a  moderate  degree  of  anaemia,  but  is  lessened  when 
diluted  with  water,  as,  when  this  is  done,  the  microbes  are  destroyed 
more  slowly  and  with  greater  difficulty,  Watson-Cheyne  found,  in  his 
experiments  made  for  the  purpose  of  ascertaining  the  presence  of  micro- 
organisms in  the  living  tissues,  that  while  they  were  not  present  when 
the  animal  was  in  good  condition,  yet  if  the  vitality  of  the  animal  was 
depressed,  say,  ])y  administering  large  doses  of  phosphorus  for  some 
time,  microbes  could  be  found  at  times  in  the  blood  and  tissues  of  the 
bod}-.  Again,  it  has  been  found  that,  while  some  micro-organisms  when 
introduced  into  the  living  body  in  small  number  disappear  after  a  short 
time,  when  a  large  quantity  of  the  culture  is  introduced  the  tissues  of 
the  body  are  ijijured  by  the  pre-existing  ptomaines  and  the  microbes  re- 
tain tiieir  vitality  and  often  cause  inflammation  of  the  organ  in  Avhich 
they  locate.  The  conditions,  then,  upon  which  depend  the  preservation 
of  liealth  in  the  event  of  the  entrance  of  pathogenic  microbes  into  the 
body,  are  :  1 .  The  number  of  microbes  introduced.  2.  Absence  of  a  locus 
minoris  resistentiae.    3.  Active  elimination  through  the  excretory  organs. 


LOCALIZATION    OF    BACTERIA.  141 

LOCALIZATION    OF    BACTERIA. 

Ever^'  surgeon  has  had  frequent  opportunities  to  observe  eases  in 
which  a  slight  subcutaneous  injury'  was  followed  by  a  destructive  inflam- 
mation,— an  inflammation  not  caused  b}'  the  trauma  alone,  but  b}'  the 
trauma  giving  rise  to  localization  of  pathogenic  microbes  in  the  tissues 
altered  b}'  the  injury.  Thus,  Chaveau  has  shown  experimentally  that 
a  subcutaneous  contusion  furnishes  an  excellent  condition  for  the  locali- 
zation of  pathogenic  bacteria  carried  to  the  part  by  the  circulating- 
blood.  When  he  injected  a  putrid  fluid  directly  into  the  circulation  of 
young  rams  shortl}'  before  crushing  subcutaneously  one  of  the  testicles, 
the  injured  organ  alwa^'s  became  the  seat  of  septic  gangrene,  while  with- 
out such  injection  the  testicle  disappeared  completel}'  by  necrobiosis 
and  absorption.  Gangrene  only  occurred  if  the  putrid  fluid  contained 
bacteria ;  it  did  not  take  place  when  the  injected  fluid  had  been  sterilized 
b}'  filtration.  Extensive  subcutaneous  injuries,  as  scA^ere  contusions, 
rupture  of  tendons  or  muscles,  and  comminuted  fractures,  are  not  fol- 
lowed b}^  suppuration  unless  the  injured  tissues  become  subsequently  the 
seat  of  infection  with  pus-microbes.  A  patient  maj'  have  been  the  sub- 
ject of  tubercular  infection  for  an  indefinite  period  of  time,  and  yet  ma}' 
present  the  appearances  of  ordinar}-  health,  until  some  slight  injur}- 
determines  localization  of  the  bacillus  in  the  part  injured, — an  occur- 
rence which  is  followed  b}'^  a  localized  tuberculosis  from  which,  later, 
regional  and  general  dissemination  takes  place,  to  which  tlie  patient 
finally  succumbs,  unless  the  tubercular  focus  is  removed  bj'  an  early 
operation.  These  facts  suggest  very  strongly  that,  in  the  hypothetical 
cases,  suppuration  and  tuberculosis  would  not  have  occurred  in  the  part 
injured  without  the  injury,  and  that  the  injury  certainly  loould  not  have 
produced  suppuration  or  tuberculosis  unless  the  respective  piatients  had 
been  infected  previously  with  specific  micro-organisms.  The  injur}'  in 
these  cases  created  a  so-called  locus  minoris  resistentiae,  which  may 
signif}'  one  of  two  things  :  (1)  Diminution  or  suspension  of  the  vital 
resistance  on  the  part  of  the  injured  tissues  to  the  action  of  pathogenic 
microbes ;  or  (2)  the  injury  so  alters  the  tissues  that  bacteria,  which 
were  present  in  the  circulation  without  having  given  rise  to  symptoms, 
become  arrested,  and  find  at  the  same  time  at  the  seat  of  localization  the 
uecessar}-  conditions  for  their  reproduction.  Heuber  studied  experi- 
mentally the  efiect  of  chemical  irritation  of  tissues  in  determining  locali- 
zation of  the  bacillus  of  anthrax.  The  experiments  were  made  on  rabbits, 
in  which  by  the  external  application  of  croton-oil  to  the  ear  he  produced 
a  tissue-lesion  b}-  the  inflammation  which  followed.  One  ear  was  thus 
treated,  the  other  being  left  in  a  normal  condition  in  order  to  compare 
the    results  of  localization  of  anthrax   bacilli  in  inflamed    and    normal 


142  PRINCIPLES   OF    SURGERY. 

vessels.  As  soon  as  the  inflammation  was  established,  a  pure  culture 
of  anthrax  bacilli  was  inserted  subcutaneously  at  the  root  of  the 
tail ;  this  place  was  selected  in  order  to  make  the  infection  as  far  as 
possible  from  the  inflamed  ear.  In  some  cases  the  croton-oil  was  applied 
after  the  inoculation.  Immediately  after  the  death  of  the  animal,  both 
ears  were  cut  off  and  carefully  preserved  for  subsequent  examination, 
and,  at  the  same  time,  serum  and  blood  were  separately'  taken  from  the 
inflamed  ear  and  preserved  in  sterilized  glass  tubes. 

The  results  of  a  number  of  tliese  experiments  enabled  the  author 
to  assert  that  in  all  stages  of  the  inflammation  the  bacilli  were  never 
found  outside  the  walls  of  the  capillary  blood-vessels  in  the  crotonized 
ear.  Their  number  within  the  l)lood-vessels  depended  upon  the  condition 
of  the  inflamed  vessels.  During  the  first  stage  of  inflammation,  marked 
by  oedema  without  suppuration,  more  bacilli  were  found  within  the  in- 
flamed vessels  than  in  the  corresponding  vessels  of  the  opposite  ear. 
During  the  suppurative  stage  the  bacilli  disappeared  from  the  vessels. 
During  the  third  stage,  when  granulations  commenced  to  form,  a  com- 
plete change  was  again  observed  in  the  bacteriological  condition  of  the 
inflamed  part.  The  height  of  this  stage  is  reached  on  the  tenth  day. 
During  this  stage  the  bacilli  re-appear  in  the  inflamed  tissue,  where  they 
can  be  seen  in  considerable  number,  especially  in  the  interior  of  new 
capillar^'  vessels.  During  cicatrization  the  number  of  bacilli  in  a  cor- 
responding area  of  both  ears  was  about  the  same. 

From  these  observations  the  author  concludes  that  the  bacillus  of 
anthrax  finds,  in  a  soil  prepared  by  inflammatian  induced  with  croton-oil, 
a  locus  minoris  resistentise,  which  presents  more  favorable  conditions  for 
its  localization  and  growth  than  the  tissues  in  other  parts  of  the  body. 
Suppuration  appeared  to  neutralize  the  anthracic  process  by  the  destruc- 
tive effect  of  the  pus-ptomaines  upon  the  bacilli. 

The  conclusions  which  he  has  drawn  from  his  experiments  may  be 
summarized  as  follows :  Localization  of  pre-existing  micro-organisms  in 
tissues  prepared  by  injury  or  disease  takes  place,  provided  that  the 
necessar}^  conditions  for  their  growth  are  present.  In  looking  over 
different  pathological  conditions  we  frequentl}^  meet  with  a  so-called 
locus  minoris  resistentise ;  at  any  rate,  if  we  search  only  for  that  which 
should  mean  what  has  been  described  above,  it  is  not  diflflcult  to  conceive 
how  slight  injuries,  wounds,  contusions,  etc.,  should  in  this  manner  give 
rise  to  serious  affections.  But  not  only  do  direct  tissue-lesions,  as 
haemorrhage,  necrosis,  hj'perjemia,  fractures,  etc.,  act  in  this  manner,  but 
a  variety  of  pathological  conditions  of  a  general  nature  maj'^  serve  the 
same  purpose,  as  imperfect  digestion,  enfeebled  circulation  and  respira- 
tion,  and    particular!}'  irregular   distribution  of  blood   resulting  from 


LOCALIZATION    OF    BACTERIA.  143 

exposure  to  cold.  All  these  ill-defined  conditions  belong  here,  and 
through  their  instrumentalities  the  localization  of  infective  microbes  is 
favored.  In  secondar}'  or  mixed  infection  the  microbes  which  exist  in 
the  tissues  first  prepare  the  soil  for  the  arrest  and  germination  of  other 
bacteria  which  ma}'  reach  the  circulation. 

Muskatbliith  studied  experimentally  the  fate  of  anthrax  bacilli  when 
introduced  directly-  into  the  trachea  by  injection  through  the  larynx,  or 
tlirougli  a  tracheotom}^  wound.  From  the  results  which  he  obtained  he 
concludes  that  the  bacilli  can  enter  the  circulation. through  the  bronchial 
mucous  membrane,  and  that  the  juice-canals  and  lymphatics  are  the 
channels  through  which  the  infection  takes  place.  It  appeared  strange 
to  the  autlior  that  no  bacilli  could  be  found  in  leucocytes,  but  alwaj^s 
only  in  epithelial  cells.  Final  localization  of  the  bacilli  which  have 
entered  the  circulation  through  the  lungs  takes  place  in  distant  organs 
by  implantation  upon  the  endothelial  lining  of  the  capillar}'  vessels. 

Other  experimenters  aflOirm  that  if  the  anthrax  bacilli  are  injected  in 
moderate  quantities  into  the  circulation  of  animals,  they  disappear  soon 
from  the  blood  without  having  produced  any  pathogenic  etfects  ;  but,  if 
in  animals  thus  infected  a  contusion  is  produced  in  some  part  of  the 
body,  the  bacilli  pass  out  of  the  injured  vessels  into  the  connective  tissue 
along  with  the  blood,  germinate  there,  and  soon  cause  the  formation  of 
the  characteristic  inflammatory  product,  the  disease  becomes  diflJused, 
and  the  animals  die  of  anthrax.  Localization  of  the  bacillus  of  tubercu- 
losis affords  an  interesting  subject  for  experimental  research  and  clinical 
study. 

The  late  distinguished  Professor  von  Yolkmann,  from  an  extensive 
clinical  experience,  came  long  ago  to  the  important  and  practical  con- 
clusion that  a  severe  trauma  seldom,  if  ever,  gives  rise  to  tuberculosis 
at  the  seat  of  injury;  and,  on  the  other  hand,  that  in  cases  where  tuber- 
culosis develops  in  consequence  of  any  injury,  the  trauma  is  always 
slight,  sometimes  almost  insignificant.  The  experience  of  almost  every 
surgeon  will  agree  with  these  statements.  Yolkmann  maintains  that  the 
active  tissue  changes  which  follow  a  severe  trauma  during  the  reparative 
process  counteract  the  growth  and  propagation  of  the  bacillus.  Luecke 
attributes  to  exposure  to  cold  an  important  role  in  the  causation  of 
tubercular  and  other  infective  forms  of  inflammation,  as  he  asserts  that 
the  sudden  diminution  of  blood-supply  to  the  cutaneous  surface  causes 
internal  congestions,  Avliich  favor  the  localization  of  pathogenic  microbes 
in  some  one  of  the  congested  organs,  otherwise  predisposed  to  the  specific 
inflammation.  Scliiiller  studied  the  localization  of  the  tubercular  virus 
experimentally  in  the  same  manner  as  others  have  studied  the  locali- 
zation of  pus-microbes.     He  inoculated  animals  with  the  products   of 


144  PRINCIPLES   OF    SURGERY. 

tubercular  intlaninuition,  subsequently  produced  contusions  and  sprains 
of  joints,  and  observed  that  localization  usually  occurred  at  the  seat  of 
injur3\  If  the  tubercular  virus  was  iutroduced  b}'  iuhalatiou,  the  same 
typical  lesions  occurred  in  the  injured  joints  as  when  infection  was  prac- 
ticed in  a  more  direct  manner.  In  all  cases  the  {)roduct  of  the  local 
joint-lesion  corresponded  with  the  character  of  the  material  introduced 
through  some  remote  point.  Surgeons  are  well  aware  of  the  danger  of 
general  infection  following  an  injury  to  a  part  or  an  oruan  the  seat  of 
local  tuberculosis,  more  particularly  in  cases  of  tubercular  disease  of 
joints  treated  by  hrisement  force.  Numerous  cases  are  recorded  where 
this  procedure  was  followed  within  a  few  days  by  general  miliarj^  tuber- 
culosis and  a  speed}^  death.  In  all  cases  where  a  locnl  tuberculosis 
develops  in  consequence  of  an  injury,  we  must  take  it  for  granted  that 
the  injured  part  contained  the  essential  cause  of  the  disease,  the  bacillus 
of  Koch,  and  that  the  lesions  caused  by  the  trauma  created  the  necessary 
conditions  for  its  reproduction  ;  or,  if  the  injured  tissues  at  the  time  are 
sterile,  that  they  serve  the  purpose  of  a  locus  minoris  resistentiae  for 
bacilli  which  might  reach  them  through  the  circulation.  The  frequency 
with  which  suppuration  occurs  without  any  visible  infection-atrium  has 
led  bacteriologists  to  investigate  with  special  care  and  diligence  localiza- 
tion of  pus-microbes. 

Rosenbach  ascertained,  bj^  numerous  experiments,  that  acute  suppu- 
rative osteomyelitis  could  only  be  produced  by  injecting  pus-microbes 
directly  into  the  circulation  and  by  injuring  the  medullar}-  tissue  a  few 
days  before  or  after  the  inoculation.  Kocher,  Becker,  and  Krause 
repeated  the  experiments  of  Rosenbach,  and  came  essentially  to  the 
same  conclusions.  Both  Kocher  and  Rosenbach  look  upon  the  altered 
circulation  in  the  injured  part  as  the  essential  condition  which  determines 
localization  of  the  pus-microbes  floating  in  the  blood-current ;  at  the 
same  time  they  admit  that  the  immediate  tissue-lesions,  haemorrhage, 
and  necrosis  may  have  the  same  effect.  Upon  the  same  theory,  Kocher 
explains  the  occurrence  of  traumatic  suppurative  strumitis  in  a  hyper- 
plastic struma.  If  non-septic  pus  is  injected  into  the  circulation  of 
healthy  animals  in  moderate  quantities  no  serious  results  are  produced, 
as  the  pus-microbes  are  soon  eliminated  through  the  kidneys.  If,  how- 
ever, the  pus-microbes  attach  themselves  in  the  circulation  to  some 
foreign  substance  which  prevents  such  elimination,  suppuration  will 
follow.  A  number  of  experiments  made,  among  others  b}'  Ribbert,  on 
the  production  of  myo-  and  endo-  carditis  in  rabbits,  have  shown  that 
abscesses  can  be  produced  in  other  organs  if  the  pyogenic  microbes  are 
attached  to  foreign  bodies  which  cannot  pass  through  the  pulmonary 
capillaries.     Thus,  Ribbert  was  able  to  produce  m3'ocarditis  by  using  a 


LOCALIZATION    OF    BACTERIA.  145 

cultivation  of  staplij-lococcus  p3-ogenes  aureus  on  potato,  if  he  took  the 
precaution,  in  removing  the  culture  from  the  surface  of  the  potato,  to 
scrape  oft'  also  the  superficial  surface  of  the  potato  itself.  The  particles 
of  potato  injected  with  the  microbes  determined  sui)puration  b}'  causing 
localization  of  the  microbes,  as  the  foreign  bodies  were  too  large  to  pass 
through  the  capillar}-  vessels  and  were  not  capable  of  removal  bj' 
absorption. 

The  influence  of  a  trauma  in  determining  localization  of  microbes 
circulating  in  the  blood  is  well  shown  by  the  experiments  which  have 
been  made  to  produce,  artificiall}',  endocarditis  in  animals.  0.  Rosen- 
bach  made  the  first  experiments  of  this  kind.  He  observed,  in  his 
experiments  on  animals  and  in  post-mortem  examinations  in  cases  of 
ulcerative  endocarditis,  microbic  emboli  in  the  valves  of  the  heart  and  in 
the  infarcts  of  other  organs,  and  classifies  this  afli'ection  with  pj'seraia. 
The  more  frequent  occurrence  of  endocarditis  in  the  left  side  of  the 
heart  than  tlie  right  he  explains  by  assuming  that  the  microbes  find  a 
better  soil  in  the  arterial  blood,  as  when  the  aft'ection  occurs  in  the  foetus 
during  intra-uterine  life,  when  the  blood  in  both  sides  of  the  heart  is  of 
about  the  same  composition,  the  valves  in  both  sides  are  aft'ected  with 
the  same  frequency.  Orth  and  Wj'ssokowitsch  found  that  staphA-lococci 
could  be  injected  into  the  blood  of  a  rabbit  without  apparent  injur}'  to 
it,  but  if  before  the  injection  a  slight  mechanical  injury  was  inflicted  on 
one  of  the  valves  of  the  heart,  t3'pical  endocarditis  was  at  once  produced. 
The  injur}'  was  produced  with  a  small  rod,  which  was  introduced  into 
the  jugular  vein  on  tlio  riizlit  side.  The  endocardial  lesion  always 
corresponded  to  the  seal  of  tlie  injuiy.  Similar  results  were  obtained 
by  Frankel  and  Siinger. 

Rinne  came  to  different  conclusions  in  reference  to  injured  tissues 
serving  as  a  locus  minoris  reaUtentise  in  the  causation  of  inflammation 
due  to  the  presence  of  microbes.  He  injected  pure  cultures  of  the 
diflferent  kinds  of  pus-microbes  directly  into  the  circulation  of  animals, 
and  found  that,  as  a  rule,  no  harm  resulted.  In  rabbits  he  injected  from 
2  to  3  Pravaz  S3-ringefnls  of  unfiltered,  distilled  water,  holding  in 
suspension  pure  cultures,  and,  after  repeating  this  dose  several  times, 
inflicted  all  kinds  of  subcutaneous  lesions  without  causing  suppuration. 
Only  in  a  few  instances  were  p3'^8eraic  metastases  observed,  and  these 
occurred  usually  onl)-  in  cases  where  undiluted  gelatin  cultures  were 
used.  In  several  dogs  he  made  subcutaneous  fractures  and  then  injected 
large  doses  of  cultures  of  pus-microbes,  suspended  in  distilled  water, 
into  the  peritoneal  cavity,  but  no  suppuration  occurred  at  the  seat  of 
trauma.  In  six  rabbits  he  fractured  the  femur  subcutanoousl}-  and  then 
injected  pure  cultures  into  the  jugular,  or  one  of  the  auricular,  veins,  but 


1  IH  PRINCIPLKS   OF    SURGERY. 

onlj'  in  one  of  thorn  did  osteomyelitis  occur  at  the  seat  of  fracture.  In 
two  experiments  where  he  injected  osteomyclitic  pus  diluted  with 
distilled  water  the  seat  of  fracture  suppurated,  and  in  these  cases 
abscesses  were  also  found  in  the  heart-muscle  and  the  kidne3'S  at  the 
autopsy.  It  is  difficult  to  explain  the  discrepancy  between  the  results 
obtained  hy  Rinne  and  the  other  experimenters  who  have  been  quoted, 
as  the  same  kind  of  animals  and  inoculation  material  were  used,  and  the 
experiments  were  conducted  in  the  same  manner.  The  fact  remnins^ 
and  is  abundantly  vouched  for  by  clinical  experience,  that  a  subcutaneous 
injury,  if  the  tissues  remain  sterile,  does  not  give  rise  to  inflammation, 
and  that  many  inflammatory  processes  are  established  immediately  or  soon 
after  an  injury,  and  in  the  inflammatory  product  the  presence  of  j)atho- 
genic  bacteria  can  be  demonstrated  by  microscopical  examination,  cultiva- 
tion, and  inoculation  experiments.  A  number  of  well-authenticated  cases 
of  osteomyelitis  after  simple  subcutaneous  fracture  have  been  recorded 
where  the  infection  could  be  traced  to  a  slight  peripheral  suppurative 
lesion.  The  same  can  be  said  of  many  cases  of  suppurative  osteo- 
myelitis which  occur  w-ithout  fracture,  where  the  exciting  cause  can  be 
referred  to  some  slight  injury,  or  exposure  to  cold,  and  the  essential 
cause  can  be  located  in  some  pus-producing  lesion  in  a  distant  part,  and 
having  no  direct  vascular  connections  with  the  suppurating  medullary 
tissue.  From,  «.  scientific  and  practical  stand-point,  it  is  important  to 
recognize  the  existence  of  local  conditions  in  the  tissues  created  by  a 
trauma,  or  antecedent  pathological  conditions,  to  exjylain  the  localization 
of  floating  microbes  and  the  j^^oducfioji  of  local  affections  by  their 
uniform  presence  and  constant  pathogenic  action. 

SECONDARY   OR    MIXED   INFECTION. 

Antecedent  pathological  products  may  serve  the  same  purpose  in 
the  body  as  a  trauma  in  the  determination  of  localization  of  pathogenic 
microbes.  Suppuration  in  a  tumor,  or  a  hyperplastic  gland  with  an 
intact  cutaneous  covering,  indicates  that  in  the  tumor  or  swelling  pus- 
microbes  have  been  arrested,  and  that  they  have  been  deposited  in  a  soil 
adapted  to  their  germination  and  the  exercise  of  their  pathogenic 
qualities.  The  atypical  vascularization  in  tumors  and  the  partial 
obstruction  in  the  lumen  of  blood-vessels  in  intlammatory  swellings 
cannot  fail  in  creating  conditions  which  determine  filtration  of  bacteria- 
containing  blood.  If  the  pre-existing  pathological  product  is  the  result 
of  a  previous  infection,  and  serves  as  a  medium  for  localization  of  another 
kind  of  pathogenic  microbes,  we  speak  of  the  combined  process  due  to 
the  presence  of  two  varieties  of  micro-organisms  as  a  mixed  infection. 
The  first  positive  proof  of  the  existence  of  a  secondary  or  mixed  infec- 


SECONDARY    OR    MIXED    INFECTION.  147 

tion  was  furnished  by  Brieger  and  Ehrlicb.  These  observers  saw  a 
malignant  oedema  develop  at  the  point  where  musk  was  injected  hypo- 
dermaticall}'  in  a  severe  case  of  typhoid  fever.  The}^  found  that  in 
such  cases  a  predisposition  is  established  by  an  existing  disease  to  the 
growth  and  reproduction  of  micro-organisms,  which  may  have  been 
previousl}'  present  in  tlie  organism  without  producing  any  pathological 
lesions. 

Koch,  in  his  article  on  "  The  Etiology  of  Tuberculosis,"  alludes  to 
the  occurrence  of  mixed  infection,  as  he  states  that  he  saw  at  the  same 
time  bacilli  and  micrococci  present  in  the  same  tubercular  lesion.  In 
reference  to  the  occurrence  of  micrococci  in  tubercular  deposits  in  the 
lungs  and  spleen,  he  explained  their  presence  upon  the  supposition  that 
they  entered  the  circulation  through  ulcerations  of  the  tongue,  and  that 
they  became  arrested  in  the  capillary  vessels,  which  had  lost  their  normal 
resisting  power  by  the  tubercular  process.  Bumm  maintains  that  in 
some  patients  secondary  infection  is  a  purelj^  accidental  occurrence,  as, 
for  example,  a  tuberculous  patient  can  be  attacked  with  erj^sipelas ;  a 
lying-in  woman  suffering  from  gonorrhoea  may  become  the  subject  of 
septic  infection. 

Another  and  practicall}' more  important  variety  of  mixed  infection 
he  speaks  of  where  a  more  direct  relation  exists  between  the  different 
microbes,  in  the  sense  that  the  one  precedes  the  other  and  prepares  the 
soil  for  the  growth  of  the  latter.  These  forms  are  characterized  b}^ 
being  constantl}'  associated  with  certain  definite  microbes.  The  pneu- 
mococcus  ma}'  prepare  the  soil  for  fructification  of  the  bacillus  of  tuber- 
culosis or  the  microbes  of  suppuration  in  individuals  that  otherwise 
would  have  been  immune  to  tlie  action  of  these  micro-organisms.  The 
gonococcus  can  also  modif}'  the  mucous  membrane  of  the  genito-urinary 
tract  in  such  a  manner  as  to  render  eas^^  the  invasion  of  other  pathogenic 
microbes.  Gonorrhoeal  infection  of  the  vulvo-vaginal  gland  furnishes  a 
good  illustration.  As  long  as  the  infection  remains  purely  gonorrhoeal, 
the  acute  suppurative  stage  is  followed  b}'  a  chronic  stage  which  ma}- 
last  for  several  months,  the  swelling  gradually  subsides,  and  subsequently 
atrophy  and  sclerosis  of  the  gland  follow.  If,  however,  purulent  infec- 
tion is  added  to  the  gonorrhoea,  the  gland  soon  becomes  enlarged  and 
tender,  and  suppuration  follows.  In  the  abscess  and  its  vicinity  no 
gonococci  can  be  found;  the  pus  only  contains  pyogenic  microbes,  which 
exterminated  the  gonococci.  Cystitis  which  accompanies  gonorrhoea  is, 
again,  a  variety  of  mixed  infection.  The  stratified  epithelium  of  the 
bladder  is  impenetrable  to  the  gonococcus. 

According  to  Bumm  the  cystitis  is  maintained  by  another  species 
of  microbe  resembling  the  gonococcus,  but  differing  from  it  by  taking  a 


148  PRINCIPLES   OF    SURGERY. 

diflerent  staining.  The  gonococcus  expends  its  action  on  the  superficial 
layers  of  the  mucous  membrane  exclusively'.  Suppurative  parametritis 
following  gonorrlioia  is  analogous  to  a  gonorrhffiic  bubo,  which  is  always 
caused  1\y  a  secondary  infection  with  pus-microbes.  A  valuable  contri- 
bution to  our  Icnowledge  of  mixed  infection  has  recently  been  made  by 
Babes.  His  investigations  consist  of  a  series  of  bacteriological  studies 
of  the  tissues  of  cliildren  who  died  of  infectious  diseases.  Within  a 
few  hours  after  death  fragments  of  tissue  were  removed  from  different 
organs  wliich,  under  strict  antiseptic  precautions,  were  imbedded  in 
sterilized  cnlture  material.  In  acute  infectious  diseases,  such  as  diph- 
theria and  scarlatina,  cultures  from  the  spleen,  kidneys,  liver,  lungs,  and 
blood  yielded  numerous  colonies  of  streptococci,  putrefactive  bacteria, 
capsule  cocci,  more  rarely  staph3'lococci  and  various  bacilli.  Of  special 
interest  are  his  researches  on  the  manner  of  localization  and  extension 
of  the  secondary  invasion  after  ditferent  primary  diseases.  In  8  cadavers 
he  found  one  or  more  species  of  bacteria  in  the  internal  organs.  In  a 
case  of  septic  omphalitis  he  found  the  bacillus  of  green  pns.  In  6  cases 
of  different  forms  of  infections  disease  the  streptococcus  pyogenes  could 
be  cultivated  from  the  tissues,  and  only  in  1  was  the  yellow  pus-microbe 
present  in  the  culture.  Various  putrefactive  bacilli  were  cultivated  from 
5  cases.  In  some  instances  he  Avas  able  to  demonstrate  the  point  at 
which  the  diflerent  secondary  invasions  had  taken  place.  Thus,  in  a  case 
of  sepsis  after  scarlatina,  in  which  streptococci  were  found  in  every  part 
of  the  bod}',  a  streptococcus  pneumonia  was  found  in  the  lower  portion 
of  the  left  lung,  while  a  number  of  foci  in  the  upper  portion  of  the 
opposite  lung  contained  only  bacilli. 

Friinkel  and  Freudenberg  cultivated  from  internal  organs  of  3  patients 
who  had  died  of  scarlatina  the  streptococcus  p3'0genes,  and  they  maintain 
that  the  presence  of  this  microbe  is  evidence  that  a  secondary  infection 
takes  place  through  the  diseased  mucous  membrane  of  the  phar^'nx. 

Schnitzler,  after  having  observed  and  carefully  studied  a  number  of 
cases,  has  come  to  the  conclusion  that  syphilitic  ulcerations  of  the  larynx 
may  pass  into  tubercular,  as  the  sj'philitic  ulcer  furnishes  a  good  culture 
soil  for  the  bacillus  of  tuberculosis. 

Heuber  attributes  the  occurrence  of  sui)puration  and  gangrene  in 
croupous  pneumonia,  phlegmonous  inflammation  and  suppuration  in  ery- 
sipelas, and  suppuration  in  tubercular  processes  to  secondary  infection 
with  pus-microbes.  As  the  bacillus  of  tuberculosis  and  the  streptococcus 
of  erysipelas  do  not  possess  the  property  of  converting  leucocytes  and 
embryonal  cells  into  pus-corpuscles,  suppuration,  if  it  does  occur  in  these 
diseases,  can  only  be  accounted  for  b}^  admitting  the  existence  of  a 
secondary  infection  with  pus-microbes. 


ELIMINATION    OF   PATHOGENIC    BACTERIA.  149 

The  important  question  presents  itself  whether,  in  eases  of  mixed 
infection,  the  two  or  more  kinds  of  microbes  enter  the  organism  at  the 
same  time,  or  whether  primary'  infection  prepares  the  way  for  the  en- 
trance and  fructification  of  the  microbes  whicli  produce  the  secondary 
infection.  Pus-microbes  being  present  at  all  times  and  everj'where,  and 
perhaps  gaining  entrance  into  the  body  more  readily  than  others,  it  is 
very  easy  to  understand  why  secondary  infection  b}-  them  is  most  fre- 
quently observed.  Rosenbach  frequently'  found  in  pus  more  than  one 
kind  of  p3'ogenic  microbe.  He  often  cultivated  from  the  same  pus  two 
kinds  of  staphylococci,  or  one  variet}'  of  staphylococci  with  streptococci. 
While  antagonism  among  some  bacteria  has  been  shown  to  exist,  others 
prepare  the  soil  for  the  growth  of  a  different  variet}',  and  in  such  in- 
stances it  is  not  difficult  to  conceive  that  secondarj^  infection  is  of  fre- 
quent occurrence.  For  instance,  any  microbe  that  will  convert  mature 
tissue  into  embryonal  cells  abbreviates  and  lightens  the  work  of  pus- 
microbes  in  converting  fixed  tissue-cells  into  pus-corpuscles. 

ELIMINATION    OF    PATHOGENIC    BACTERIA. 

Having  described  the  diff"erent  wa3's  in  which  pathogenic  bacteria 
enter  the  body,  it  now  remains  to  show  in  what  manner  thej'  are  disposed 
of  in  the  event  no  harm  follows,  or  the  patient  recovers  from  the  disease 
which  they  produced.  The  probable  existence  of  disease-producing 
micro-organisms  in  the  health3'  bod}^  and  the  spontaneous  subsidence  of 
man}'  infective  processes  make  it  important  to  consider  the  wa^s  and 
means  by  which  they  are  rendered  harmless  in  the  living  bod}',  or  are 
removed  by  elimination  through  some  of  the  excretory  organs.  In  all 
infective  processes  in  which  life  is  not  destroj'ed,  and  the  products  of 
inflammation  do  not  find  their  way  to  the  surface  spontaneouslj'  or  b}^ 
operative  treatment,  the  microbes  are  either  destroj'ed  in  the  blood  and 
the  tissues  by  phagocytosis  or  are  eliminated  through  some  of  the  excre- 
tory organs  in  an  active  state.  The  rapid  disappearance  of  most  microbes 
from  the  blood  when  injected  into  the  circulation  of  health}'  animals 
would  indicate  that  an  active  warfare  is  instituted  against  them  by  the 
colored  corpuscles  of  the  blood,  in  which  the  microbes  are  defeated, — 
that  is,  destroyed.  If  some  of  the  microbes  pass  through  the  capillary 
blood-vessels  and  come  in  direct  contact  with  the  fixed  tissue-cells,  a 
similar  struggle  ensues  between  them  and  the  tissue-cells,  and  if  the  latter 
are  victorious  the  microbes  are  destro3'ed.  Successful  phagocjtosis  must 
therefore  be  considered  as  the  most  eflScient  and  desirable  way  of  dispos- 
ing of  pathogenic  bacteria  after  they  have  entered  the  tissues  or  the 
general  circulation.  But  should  phagocytosis  prove  unsuccessful  in  de- 
stroying the  microbes  which  have  reached  the  blood,  there  is  still  another 


150  PRINCIPLES    OF    SURGERY. 

wa^-  ill  which  the  unassisted  resources  of  the  organism  can  deal  with 
them  successfully,  viz.,  elimination  through  one  or  more  of  tlie  excretory- 
organs.  The  critical  discharges  of  the  ancient  authors — profuse  sweat- 
ing, diarrhoea,  and  copious  secretion  of  urine — in  the  light  of  modern 
science  have  received  a  different  significance,  as  the}'  are  now  regarded 
as  efforts  of  the  vis  medicatrix  naturae  to  throw  off  the  cause  which  pro- 
duced the  disease, — the  pathogenic  microbes  and  their  ptomaines.  The 
kidney's  and  the  mucous  membrane  of  the  intestinal  canal  are  the  organs 
most  concerned  in  the  process  of  elimination.  That  microbes  in  an 
active  state  are  eliminated  by  the  kidneys  is  shown  by  various  observa- 
tions, and  this  is  an  important  point  to  remember  as  probably  explain- 
ing certain  cases  of  pyelitis  occurring  in  patients  who  have  never  had 
any  instrument  passed,  and  in  whom  the  urethra  and  bladder  are  perfectly 
normal.  The  salivary  glands,  more  especially  the  parotid,  occasionally 
take  part  in  the  elimination  of  pus-microbes,  thus  offering  an  explanation 
of  the  not  infrequent  occurrence  of  abscesses  in  this  gland  after  suppura- 
tion elsewhere.  The  frequency  with  which  the  kidneys  are  affected  in 
cases  of  tuberculosis  furnishes  an  evidence  that  elimination  of  bacilli 
takes  place  through  these  organs.  Philipowicz  produced  tuberculosis  in 
animals  b}^  injecting  urine  taken  from  tubercular  subjects  into  the  peri- 
toneal cavity.  Neumann  found  the  specific  microbes  in  the  urine  in  cases 
of  typhus,  septicaemia,  and  pyaemia.  In  a  case  of  acute  endocarditis  and 
osteomj-elitis  he  cultivated  from  the  urine  the  staphylococcus  pyogenes 
aureus.  He  asserts  that  the  micro-organisms  which  circulate  in  the 
blood  localize  in  the  capillar}^  vessels  of  the  kidney,  wliere  they  often 
cause  minute  multiple  lesions  without  implication  of  the  entire  paren- 
chj^ma  of  the  organ.  Through  the  altered  tissues  some  of  the  microbes 
enter  the  tubuli  uriniferi,  and  are  washed  away  with  the  urine.  Phili- 
powicz found  bacilli  in  the  urine  in  anthrax  and  glanders.  Schweiger 
has  shown  conclusively,  by  his  bacteriological  researches,  that  the  urine 
from  scarlatinal  patients  is  contagious  ;  for  varicella,  typhus  recurrens, 
and  malaria  the  same  holds  true.  Schweiger  regards  all  kidnej'-lesions 
occurring  in  the  course  of  infective  diseases  of  microbic  origin.  To 
prove  that  microbes  pass  through  the  kidneys,  he  cultivated  a  bacillus 
which  Reimann  discovered  in  the  pus  of  ozsena.  This  bacillus  is  stained 
an  intense  green  color  in  a  culture  of  gelatin  and  agar  after  twentj^-four 
hours.  A  culture  of  this  bacillus  was  diluted  with  a  phj^siological  solu- 
tion of  salt  and  injected  directly  into  the  circulation.  The  experiments 
were  made  on  a  dog,  cat,  and  rabbit.  A  certain  length  of  time  inter- 
vened between  the  injection  and  the  appearance  of  bacilli  in  the  urine, 
as  though,  somewhere  on  their  way,  an  obstacle  had  been  met  with.  At 
first   only  isolated  bacilli  were   found   in   the   urine,  but  later  on  they 


DIRECT   TRANSMISSION    OF    PATHOGENIC    BACTERIA.  151 

appeared  in  larger  numbers.  Bacteriological  examinations  of  milk  have 
shown  that  different  kinds  of  pathogenic  bacteria  are  eliminated  through 
the  mammar}'  gland.  The  chapter  on  Bacteria  would  not  be  complete 
without  at  least  alluding  briefly  to  what  is  known  in  reference  to 

DIRECT    TRANSMISSION    OF    PATHOGENIC    BACTERIA  FROM  PARENTS  TO 

FCETUS. 

That  many  of  the  infectious  surgical  diseases  are  hereditary  has 
been  admitted  b}'  the  best  authorities  for  a  long  time,  and  many  tlieorics 
have  been  advanced  to  explain  their  transmission  from  parents  to  child. 
The  modern  views  on  this  subject  may  be  narrowed  down  to  two  suppo- 
sitions :  1.  Transmission  from  parents  to  child  of  a  predisposition  to 
certain  diseases.  2.  Direct  transmission  from  parents  to  foetus  of  the 
essential  cause  of  the  disease.  The  supposed  hereditarj'  predisposition 
is  interpreted  as  meaning  some  congenital  anatomical  or  phj'siological 
defects  in  the  tissues,  which  render  the  organisms  unduly'  susceptible  to 
the  action  of  post-natal  microbic  infection.  The  existence  of  minute 
anatomical  defects  of  blood-vessels,  lymphatic  vessels  and  glands,  con- 
nective-tissue spaces,  etc.,  has  been  advanced  in  explanation  of  a  greater 
liability  of  infection  w'ith  floating  microbes,  which  enter  the  circulation 
after  birth. 

An  inherited  defective  vital  resistance  on  the  part  of  the  tissues  to 
the  action  of  bacteria  is  also  considered  b^-  many  in  the  light  of  a  con- 
genital influence  in  the  causation  of  disease.  The  above-mentioned 
conditions  are  recognized,  but  no  satisfactory,  demonstrative,  or  experi- 
mental proofs  of  their  existence  have  as  ^et  been  furnished,  and  yet  the 
immunit)^  of  some  animals  to  certain  diseases  cannot  be  explained  in  any 
other  way  than  in  attributing  to  the  tissues  anatomical  or  phj'siological 
properties  which  protect  the  organism  against  the  action  of  certain 
micro-organisms,  which,  in  other  animals  not  so  protected  b}'  inherited 
qualities,  produce  a  serious  or  fatal  disease.  Clinical  observation  also 
teaches  us  that  a  great  difference  exists  among  different  persons  in  refer- 
ence to  the  degree  of  susceptibilit}-  to  the  same  form  of  infection.  In 
many  persons,  for  instance,  inoculation  with  a  pure  culture  of  tubercle 
bacilli  would  be  a  perfectly  harmless  procedure ;  in  some  it  would  be 
followed  by  a  localized  tubercular  process,  which  in  the  course  of  time 
might  heal  spontaneousl}' ;  while  in  a  few,  rendered  more  susceptible  to 
this  form  of  infection  by  hereditar}'-  or  acquired  causes,  inoculation  with 
the  same  number  of  bacilli  would  be  followed  b}^  a  severe  form  of  local 
tuberculosis,  soon  to  be  followed  by  regional  and  general  dissemination 
and  deatli.  The  same  can  be  said  of  nearlj'  all,  if  not  all,  infectious 
diseases.     If  their  existence  has  not  been  demonstrated ,  ice  are,  neverfhe- 


152  PRINCIPLES    OF    RUr?GERY. 

less^  forced  to  accept  the  influence  of  certain  as  yet  unknown  conditions 
inherent  in  the  tissues,  and  which  are  often  traceable  to  a  congenital  cause 
or  causes,  which  favor  or  resist  post-natal  microbic  diseases.  During  the 
last  few  years  some  progress  has  been  made  in  showing  that  hereditary 
diseases,  in  many  instances  at  least,  are  due  to  a  more  direct  cause — 
transmission  from  parents  to  foetus  of  the  essential  cause  of  the  disease — 
l)athogenic  microbes.  Although  our  knowledge  of  the  intra-uterine 
origin  of  microbic  diseases  is  as  ^-et  imperfect,  there  can  be  no  doubt 
that  future  study  and  research  will  clear  up  many  dark  points,  and  fur- 
nish satisfactory  demonstrative  explanations  of  the  direct  and  indirect 
hereditary  influences  in  the  causation  of  disease.  It  is  well  known  that 
sraall-pox,  measles,  and  scarlatina  are  directly  transmissible  from  mother 
to  foetus.  Numerous  well-authenticated  cases  of  these  diseases  occur- 
ring in  newborn  children  have  been  recorded.  Lebedetf  reports  a  case 
of  premature  birth  which  occurred  eight  days  after  the  mother  had 
recovered  from  erysipelas.  The  child  died  ten  minutes  after  birth,  and 
the  author  found  Fehleissen's  streptococcus  in  the  lymphatic  vessels,  in 
the  diseased  skin,  and  in  the  umbilical  cord,  but  none  in  the  placenta. 
The  author  believes  that  the  streptococci  were  transported  from  the 
lymphatic  vessels  of  the  lower  extremities  of  the  mother  through  the 
lymphatics  of  tlie  uterus  into  the  placental  vessels,  and  from  the  mater- 
nal into  the  foetid  circulation.  Ahlfeld  and  Marchand  report  the  case  of 
a  woman  who  presented  no  symptoms  of  disease  except  a  moderate 
pallor  and  tympanitic  distention  of  the  abdomen.  After  a  normal  labor 
she  gave  birth  to  her  second  child  ;  eight  hours  after  delivery  the  patient 
died  in  collapse,  for  which  no  cause  could  be  found.  The  autopsy  re- 
vealed anthrax  as  the  cause  of  death.  The  child  died  four  da3^s  after 
birth  from  the  same  cause.  The  mother,  as  was  later  ascertained,  con- 
tracted the  disease  in  sorting  horse-hair,  and  the  child  was  infected 
directly  through  the  placental  circulation.  Sangalli  found  the  bacilli  of 
anthrax  in  the  blood  of  a  foetus  from  a  woman  who  had  died  of  anthrax. 
In  opposition  to  Golzi  and  others,  he  affirms  that  the  transmission  of 
the  disease  from  mother  to  foetus  could  only  have  taken  place  by  the 
passage  of  the  bacilli  or  spores  from  the  maternal  to  the  foetal  circulation 
through  the  placental  vessels.  Netter  reports  a  carefully-observed  case 
of  direct  transmission  of  the  diplococcus  of  pneumonia  from  mother  to 
foetus.  The  mother  was  a  Vl-para,  pregnant  eight  months,  when  she  was 
attacked  with  croupous  pneumonia,  Avhich  terminated  on  the  seventh  day 
in  recovery.  On  the  ninth  day  after  the  attack  she  was  delivered  of  a 
living  child.  The  child  died  on  the  lifth  day  after  birth.  The  autopsy 
revealed  lobar  pneumonia  involving  the  right  upper  lobe,  double  fibrinous 
pleuritis,  pericarditis,  suppurative  meningitis,  and  otitis  media  on  both 


DIRECT    TRANSMISSION    OF    PATHOGENIC    BACTERIA.  153 

sides.  Bacteriological  examination  of  the  diflerent  inflammatory  products, 
as  well  as  of  the  blood  taken  from  the  left  ventricle,  showed  the  presence 
of  FrJinkel's  diplococcus  pneumoniae.  One  of  the  strongest  evidences 
of  direct  transmission  of  pathogenic  microbes  from  mother  to  foetus 
through  the  placental  circulation  is  the  often-quoted  observation  made 
by  Johne.  An  eight  months'  foetus  was  taken  from  a  cow,  the  subject 
of  advanced  tuberculosis.  No  tuberculous  products  were  found  in  the 
placenta  or  the  uterus,  but  in  the  loAver  lobe  of  the  right  lung  of  the 
I'oetus  a  nodule  tlie  size  of  a  pea  was  detected,  containing  four  caseous 
centres.  The  bronchial  glands  were  tubercular.  The  liver  contained 
numerous  miliary  nodules.  All  the  lesions  presented  under  the  micro- 
scope the  characteristic  histological  structure  of  tubercle.  Jani  has 
examined  the  healthy  sexual  organs  of  nine  phthisical  patients  for 
tubercle  bacilli.  No  bacilli  were  found,  in  an}^  of  these,  in  the  semen 
from  the  vesiculffi  seminalis,  but,  on  the  other  hand,  in  5  out  of  8  cases, 
a  few  were  found  in  the  testicle,  and  in  4  out  of  6  in  the  prostate  gland. 
He  further  examined  two  women  who  died  of  pulmonary  phthisis,  the 
ovaries  in  both  presenting  negative  results.  In  one  case  of  chronic 
pulmonary  phthisis,  with  extensive  intestinal  tuberculosis,  he  examined 
the  Fallopian  tubes,  and  found  tubercle  bacilli.  He  believes  that  the 
tuberculous  virus  can  be  transmitted  from  parents  to  offsi)ring  in  one  of 
two  waj^s  :  1.  Through  the  semen  of  the  male.  2.  Through  the  migration 
of  bacilli  into  the  uterus  from  the  abdominal  cavit3^  The  frequency 
with  which  the  Fallopian  tubes  are  the  seat  of  tuberculous  lesions  make 
it  more  than  probable  that  the  ovum,  on  its  wa}'  from  the  ovaries  to  the 
uterine  cavity,  is  infected  with  bacilli.  It  also  requires  no  stretch  of 
the  imagination  to  understand  how  the  spermatozoa  in  the  testicle  or  on 
its  wa^'  to  the  vesiculse  seminalis  can  be  contaminated  with  bacilli,  and 
thus  the  disease  directly  transmitted  from  fatlier  to  fretus. 

That  syphilis  is  a  microbic  disease  can  no  longer  be  doubted, 
and  that  it  is  one  of  the  diseases  which  is  most  frequently  transmitted 
from  parents  to  offspring  is  well  known. 

That  pathogenic  micro-organisms  may  exist  in  the  blood  of  ap- 
parenth'  healthy  mothers  without  doing  any  harm  is  well  illustrated 
by  children  who  have  been  born  suflTering  from  suppurative  osteo- 
m\'elitis,  while  the  mothers,  through  whose  blood  only  the  micro- 
organisms could  have  come,  showed  no  evidences  of  disease.  Rosenbach 
reports  such  a  ease  in  his  artice  on  acute  osteomyelitis.  Transmission 
of  microbic  diseases  through  the  placental  circulation  has  been  made  the 
subject  of  experimental  inquiry-.  Strauss  and  Chamberland  experimented 
on  guinea-pigs  to  prove  that  intra-uterine  transmission  of  anthrax  from 
mother  to  offspring  is  i^ossible.     Gravid  animals  Avere  inoculated  with 


154  PRINCIPLES   OF    SURGERY. 

the  virus  of  anthrax,  ami  the  foetuses  examined  immediately  after  death. 
Blood  taken  from  tlie  cavities  of  the  heart  and  liver,  examined  under  the 
microscope,  never  showed  bacilli.  Cultivation  experiments  were  made 
with  the  foetal  blood  in  veal-bouillon,  and  these  proved  that  iu  some 
instances  the  l)lood  of  all  foetuses  from  the  same  mother  contained 
bacilli ;  sometimes  from  the  same  litter  all  cultures  remained  sterile, 
while  in  some  tlie  blood  of  only  one  foetus  would  yield  a  positive  result. 
From  these  experiments  the  authors  came  to  the  conclusion  that  the 
tissues  of  the  placenta  offer  no  insurmountable  obstacle  to  the  passage 
of  the  bacillus  of  anthrax  from  the  maternal  into  the  foetal  circulation. 
Kowbassoft"  came  to  more  positive  results  in  his  experiments.  In  all  of 
his  experiments  the  foetuses  of  the  infected  animals  contracted  the  dis- 
ease in  utero.  He  also  found  that  time  played  an  important  role  as  far 
as  the  number  of  bacilli  in  the  foetus  was  concerned,  as  the  longer  the 
period  which  intervened  between  the  inoculation  and  the  death  of  the 
mother,  the  more  numerous  were  the  bacilli  in  the  foetal  organs,  showing 
that  the  migration  of  microbes  from  the  maternal  to  the  foetal  side  of  the 
placenta  is  continuous.  Inoculation  with  attenuated  virus  proved  that 
intra-uterine  transmission  took  place  more  slowly.  Inoculation  of  gravid 
animals  with  a  very  strong  culture  nearly  always  proved  fatal  to  the 
foetuses.  Manzeri  believes  that  direct  transmission  of  microbes  from 
mother  to  foetus  through  normal  placental  vessels  is  impossible.  As 
the  I'esult  of  an  extensive  study  of  the  literature  of  this  subject  and  of 
original  experiments,  he  has  come  to  the  conclusions  that  no  formed 
elements  naturally  pass  out  of  the  mother's  blood  into  the  foetal  circula- 
tion. Cinnabar,  Indian  ink,  carmine,  and  other  finely-divided  pigment 
materials  were  injected  into  the  jugular  veins  of  animals  far  advanced  in 
pregnancy,  but  in  no  case  could  any  trace  of  the  substance  emploj^ed  be 
found  in  the  foetus.  According  to  his  views,  passage  of  formed  elements 
can  only  occur  when  the  placenta  becomes  diseased  by  inflammation,  or 
is  partially  detached  so  that  the  walls  of  the  villi  are  destro3^ed.  He 
maintains  that  only  under  these  conditions  can  pathogenic  micro- 
organisms be  transmitted  from  the  mother  into  the  foetal  blood.  Most  all 
authors  agree  that  when  extravasations  or  other  pathological  processes 
occur  in  the  placental  attachment,  the  direct  entrance  of  microbes  from 
the  maternal  into  the  foetal  circulation  is  not  only  possi]>le,  but  a 
probable  occurrence.  Abnormality  of  the  placental  circulation  must, 
therefore,  be  recognized  as  a  condition  which  favors  the  occurrence  of 
hereditary  microbic  disease.  Both  clinical  observation  and  experimental 
research  leave  no  room  for  doubt  that  in  some  infectious  diseases,  at  least, 
heredity  is  traceable  to  direct  transmission  of  the  specific  microbes,  either 
by  meayis  of  transportation  by  the  spermatozoa  to  the  ovum,  or  by  their 


DIRECT    TRANSMISSION    OF   PATHOGENIC    BACTERIA.  155 

entrance  through  the  thin  wall  which  separates  the  maternal  from  the 
fcetal  circulation.  It  is  no  more  difficult  to  explain  the  migration  of 
microbes  through  such  a  thin  septum  tlian  their  transportation  from  one 
tissue  to  another,  and  from  organ  to  organ  in  other  parts  of  the  body, 
more  especiall}'  as  the  anatomical  conditions  for  mural  implantation  in 
the  placental  vessels  are  most  favorable  for  such  an  occurrence. 


CHAPTER  VI. 

Necrosis.  , 

Necrosis,  gangrene,  mortification,  and  sphacelus  are  terms  used 
S3'nonymously  to  indicate  the  deatli  of  a  part.  Englisli  and  American 
writers  have  usualh'  restricted  tlie  meaning  of  the  word  necrosis  to  death 
of  bone,  while  the  remaining  terms  were  used  to  express  the  same  con- 
dition affecting  the  soft  tissues.  Recently  a  sharp  distinction  has  been 
made  between  necrosis  and  gangrene  from  an  etiological  stand-point, 
according  to  which  necrosis  is  said  to  have  taken  place  when  the  circu- 
lation and  nutritive  changes  in  a  part  have  completel}^  ceased  to  be 
followed  by  gangrene  as  soon  as  saprophj'tic  bacteria  invade  it  and  give 
rise  to  putrefaction.  Death  of  bone  will  never  be  described  as  gangrene, 
and  the  moist  putrefactive  form  of  gangrene  of  the  soft  tissues  will,  in 
all  probability,  be  never  designated  by  the  term  necrosis.  Necrosis  of 
bone  takes  place  in  the  same  manner  and  results  from  the  same  causes 
as  gangrene  of  the  soft  parts,  and  on  this  account  tliere  does  not  appear 
to  be  sufficient  reasons  to  apply  diflerent  terms  to  identical  processes 
occurring  in  different  anatomical  structures ;  and  3'et  b}'  long  usage  they 
have  become  so  intimately  associated  with  the  anatomical  character  of 
the  part  affected  tliat  it  is  difficult,  for  the  present  at  least,  to  drop 
either.  In  modern  literature  we  speak  of  necrosis  of  the  soft  tissues 
when  the  dead  structures  do  not  undergo  putrefaction ;  that  is,  when  this 
process  takes  place  in  the  internal  organs  not  readil}^  accessible  to 
putrefactive  bacteria.  In  its  extent  necrosis  varies  greatly ;  it  may 
involve  an  entii'e  limb,  an  entire  organ,  or  may  be  limited  to  a  single  cell. 
As  a  ph3'siological  process  it  occurs  everywhere  in  the  tissues,  being 
limited,  however,  to  individual  cells  incident  to  the  wear  and  tear  of  the 
body,  the  pulling  down  and  building  up  of  the  tissues,  the  cells  that  are 
lost  being  replaced  b}^  the  normal  process  of  regeneration.  A  simpU', 
numericall}^  increased  cell  necrosis,  without  normal  restitution,  leads  to 
atrophy, — necrosis  atrophica.  When  all  the  cells  of  a  part  undergo  death 
simultaneously,  the  circulation  corresponding  to  the  area  of  dead  tissue 
is  arrested  completely,  and  with  this  absolute  ischsemia,  plasma  circula- 
tion, and  all  functions  are,  of  course,  completelj'  suspended, — a  serious 
pathological  condition.     A  total  necrosis  has  occurred. 

(157) 


158  PRINCU'LKS    OF    SURGERY. 

ETIOLOGY. 

Necrosis  is  a  condition,  not  a  disease.  As  a  symptom  it  represents 
a  local  condition  which  has  been  bronght  about  b}'  different  causes.  The 
most  frequent  causes  of  necrosis  are  the  following : — 

Inflammation. — Inflammation  may  produce  necrosis  in  two  different 
ways  :  1.  Exudation  and  transudation  take  place  so  rapidly  that  com- 
plete stasis  is  produced  by  the  extra-vascular  pressure.  2.  The  bacterial 
cause  of  the  inflammation  is  present  in  such  large  quantities  that  the 
vitality  of  the  tissue  is  destroyed  directly  from  this  cause.  If  during 
an  acute  inflammation  the  capillary  walls  undergo  such  serious  alteration 
that  within  a  few  hours  or  daj's  the  connective-tissue  spaces  become  so 
densely  packed  with  the  corpuscular  elements  of  the  blood  that  the 
plasma  circulation  is  greatly  impeded  or  completely  arrested,  the  primary 
inflammatory  product  encroaches  upon  the  capillar}^  vessels  to  such  an 
extent  as  to  completely  arrest  the  already  sluggish  circulation.  If  such  a 
copious  and  rapidly-forming  inflammatory  exudate  give  rise  to  complete 
stasis  over  a  considerable  area,  the  extent  of  the  resulting  necrosis  will 
correspond  to  the  district  deprived  of  the  requisite  blood-supply.  The 
same  bacteria  which  produce  inflammation  frequentl}^  if  present  in 
suflScient  quantities,  also  cause  cell  necrosis.  Ogston  maintains  that  the 
staphj^lococci  invade  the  tissues  in  the  form  of  dense,  roinid  masses, 
which  advance  like  clouds  of  a  dense  vapor,  and,  coming  in  contact 
with  the  tissues,  induce  necrosis,  the  cells,  nuclei,  and  intercellular  sub- 
stance being  changed  into  a  homogeneous,  wax-like  substance  before 
purulent  liquefaction  occurs.  On  the  other  hand,  the  streptococci  of 
suppuration  invade  the  intercellular  spaces,  the  nuclei  of  the  cells  re- 
maining visible.  Bonone  found  the  staphylococcus  pyogenes  aureus  in 
such  metastatic  and  broncho-pneumonic  foci  wliich  presented  a  gangre- 
nous character.  He  maintains  that  the  staphylococcus  at  first  produces 
in  the  lungs  a  neci'osis  by  its  multiplication,  and  that  suppurative  in 
flammation  follows  later  around  the  necrotic  tissue.  Pnti-efaction  of  the 
dead  tissue  develops  in  consequence  of  the  entrance  of  saprophytic 
bacilli  through  the  bronchial  tubes.  He  verified  these  assertions  by 
experiments.  He  obtained  pure  cultures  of  the  yellow  coccus  from  such 
pulmonar}^  foci  made  by  intra-parenchymatous  pulmonary  injections,  and 
succeeded  in  producing  artificiall}^  identical  lesions  in  the  lungs  of 
animals.  The  same  result  was  obtained  by  the  intra-venous  introduction 
of  small  particles  of  elder-pith  impregnated  with  pure  cultures  of  the 
yellow  staphylococcus.  The  gangrenous  foci  produced  by  emboli  con- 
taminated with  the  yellow  coccus  presented  a  characteristic  appearance. 
The  centre  of  such  foci,  at  an  early  stage,  is  composed  of  necrotic  tissue 
and  remnants  of  dead  leucocytes.     The  dead  tissue  is  surrounded  by  a 


ETIOLOGY.  159 

granular  zone,  which  is  again  inclosed  by  a  hsemorrhagic  zone,  and 
beyond  this  an  area  of  catarrhal  pneumonia.  The  staphylococci  occupy 
the  central  portion  and  from  here  invade  the  granular  zone,  ^vhere  putre- 
factive bacteria  are  also  found.  The  pus-microbes  do  not  reach  the 
haemorrhagic  zone,  or  the  tissues  the  seat  of  catarrhal  pneumonia.  As 
Bonone  was  unable  to  produce  gangrene  of  the  lung,  either  by  parenchj^- 
matous  injections  of  other  bacteria,  as  the  pneumococcus  or  mikrosporon 
septicuvi,  or  by  aseptic  emboli  of  elder-pith,  he  naturally  came  to  the 
conclusion  that  the  gangrene  resulted  from  the  specific  ettect  of  the 
yellow  COCCUS;  He  compares  gangrene  of  the  lung  with  furuncle  of  the 
skin  from  an  etiological  stand-point.  There  can  be  no  doubt  that  the 
primary  effect  of  pus-microbes,  when  brought  in  contact  with  living 
tissue,  under  certain  circumstances,  is  to  produce  necrosis  before  sufficient 
time  has  elapsed  for  parenchj-matous  inflammation  to  become  established. 
This  occurs  in  gangrene  of  the  lung,  furuncles,  carbuncles,  and  endo- 
carditis hacteritica  staphylococcica.  In  the  ordinary  connective-tissue 
abscess,  however,  the  connective-tissue  cell  undergoes  the  ordinary  in- 
flammatory changes  before  the}*  are  converted  into  pus-corpuscles,  and 
if  gangrene  occur  it  is  owing  as  much  to  mechanical  obstruction  to  tlie 
circulation  caused  by  a  copious  exudate  as  to  the  local  toxic  effects  of 
the  pus-microbes  and  their  ptomaines.  This  difference  in  the  action  of 
pus-microbes  on  the  tissues  depends  largely  upon  the  rapidity  with  which 
they  multiply  at  the  point  of  primary  localization.  If  the  microbes  are 
rapidh'  reproduced  the  chemical  substances  which  they  produce  in  the 
tissues  are  present  in  such  large  quantities  that  the^^  destro}'  the  cell 
protoplasm,  and  cell  necrosis  takes  place  as  the  result  of  their  primar^^ 
action ;  if  the  microbes  multiply  with  less  rapidity  their  effect  on  the 
tissues  is  less  severe,  and  parenchymatous  inflammation  is  produced 
instead  of  necrosis.  Bonone  used  large  quantities  of  pus-microbes  in 
his  injections,  and  the  infected  emboli  caused  circulatory  disturbances, 
which  only  could  favor  rapid  reproduction  at  the  point  of  primarj^ 
localization.  Passet  and  Liibbert  repeated  his  experiments,  but  used 
more  diluted  cultures,  and  probably  on  this  account  they  were  never 
successful  in  producing  gangrene  of  the  lung,  while  they  frequently 
observed  the  development  of  a  pulmonary  abscess.  The  centre  of  a 
furuncle,  as  well  as  a  carbuncle,  is  occupied  by  a  mass  of  dead  connective 
tissue,  which  later  becomes  detached  by  suppurative  inflammation.  The 
connective  tissue  in  these  cases  is  killed  by  the  bacterial  cause  of  the 
suppurative  inflammation,  which,  toward  the  peripherj^,  appears  to 
become  mitigated  so  that,  behind  the  suppurating  zone,  a  wall  of  granu- 
lation tissue  is  established  which  limits  further  extension  of  the 
disease. 


160  PRINCIPLES   OF    SURGERY. 

Specific  Bacteria. — All  bacteria  which  can  produce  an  inflammation 
sufllciently  severe  to  completely  arrest  circulation  can  become  an 
indirect  cause  of  necrosis.  Among  these  can  be  included  the  pus- 
microbes  and  the  bacillus  of  anthrax.  The  necrosis  which  occurs  regu- 
larl}^  almost  in  every  case  of  anthrax  is  probably  due  to  the  intensity  of 
the  inllannnation  resulting  from  the  presence  of  the  anthrax  bacillus,  to 
secondary  Infection  with  pus-microbes,  or  to  the  combined  effect  of  both 
microbes.  The  absence  of  necrosis  in  artificially-produced  anthrax, 
when  pus-microbes  are  excluded  by  the  strictest  antiseptic  precautions, 
does  not  prove  that  tiie  anthrax  bacilli  possess  no  necrotic  effect  on  the 
tissues,  as  in  such  instances  death  follows  so  soon  that  not  sufficient 
time  intervenes  between  the  inoculation  and  the  death  of  the  animal  for 
the  local  inflammation  to  terminate  in  necrosis.  Necrosis  is,  however, 
much  more  likely  to  occur  if  the  anthracic  infection  is  complicated  by 
the  presence  of  pus-microbes.  It  is  well  known  that  certain  chemical 
substances  have  the  power  to  produce  cell  necrosis  independently  of 
their  action  to  excite  inflammation.  Digitoxin,  a  poisonous  principle 
of  digitalis,  is  one  of  these.  The  primary  effect  of  this  substance  on  the 
tissues  is  to  produce  cell  necrosis.  We  should  expect  that  some  of  the 
ptomaines  possess  similar  properties.  Ortliinaun  made  some  very  inter- 
esting experiments  in  this  direction  with  pus-microbes.  He  inoculated 
both  corneae  in  rabbits  by  making  a  puncture  with  a  needle  infected  with 
a  pure  culture  of  the  streptococcus  pj^ogenes.  One  of  the  eyes  was  irri- 
gated for  ten  minutes  with  a  warm  phj-siological  solution  of  salt, 
by  using  an  apparatus  constructed  for  this  si)ecial  purpose.  In  the  eye 
not  thus  treated  a  suppurative  keratitis  was  initiated  by  the  leucocj'tes 
from  the  conjunctival  sac  reaching  the  infected  field,  while  in  the  cornea 
treated  by  irrigation  the  streptococci  invaded  the  vascular  spaces,  and, 
multiplying  with  great  rapidity,  produced  by  their  accumulation  dilata- 
tion of  the  spaces  and  necrosis  of  the  fixed  tissue-cells. 

In  most  of  these  cases  the  central  necrosis  led  to  perforation  of  the 
cornea  and  complete  destruction  of  the  eye.  As  the  corneal  corpuscles 
in  the  necrotic  area  had  lost  their  nuclei  and  the  parenchyma  cells 
showed  no  signs  of  inflammation,  we  cannot  escape  the  conclusion  that 
cell  necrosis  was  induced  by  the  direct  action  of  the  ptomaines,  elabo- 
rated by  the  masses  of  streptococci  in  the  vascular  spaces.  The  most 
conclusive  proof  of  the  destructive  effect  of  ptomaines  on  the  tissues  has 
been  furnished  by  the  great  master  and  founder  of  modern  bacteriology, 
Robert  Koch.  In  his  experiments  on  septicaemia  in  mice  he  found, 
besides  bacilli,  a  micrococcus  in  the  neighborhood  of  the  place  of  injec- 
tion. Of  the  numerous  kinds  of  bacteria  contained  in  the  putrid  fluid 
used  for  injection,  only  the  fine  bacilli  upon  which  the  induction  of  the 


ETIOLOGY. 


161 


septicaemia  depended  and  the  chain  cocci  found  a  suitable  soil  in  the 
mouse,  while  all  the  rest  perished.  The  chain  coccus  was  never  found  in 
the  blood,  but  only  in  the  tissues  at  the  seat  of  infection.  He  found  it 
exceedingly  difficult  to  isolate  it  from  the  bacillus.  At  last  he  succeeded 
in  cultivating  it  in  the  field-mouse,  which,  as  experiments  proved,  is 
immune  to  the  bacillus  of  septicsemia.  The  chain  coccus  injected  into 
the  subcutaneous  tissue  of  the  ear  of  the  field-mouse  invaded  the  tissues 
slowl}',  causing  paleness  and  death  of  the  cells  without  extravasation. 
The  microbe  entered  and  plugged  the  capillary  vessels,  but  never  found 


Fig.  48.— Expeeimentally-produced  Growth  of  Streptococci  in  Centeb 

OF  Cornea  of  Rabbit.    Horizontal  Section,  X  40.    {Baumgarten.) 

A,  normal  cornea ;  B,  central  necrotic  portion,  corresponding  in  outline  to  the  star-shaped  streptococci  culture. 

its  way  into  the  general  circulation.  Examination  of  the  specimens 
showed  that  progressive  gangrene  occurred  in  advance  of  the  microbes, 
hence  could  have  occurred  only  by  the  action  of  ptomaines  diffused 
through  the  tissues  ahead  of  the  microbic  invasion.  Inflammation  of 
the  fixed  tissue-cells  occurred  around  the  zone  of  gangrene,  and  all 
leucoc^'tes  which  reached  the  infected  field  perished.  If  the  same  animal 
was  inoculated  at  the  root  of  the  tail,  gangrene  occurred  ond  spread  in  a 
central  direction,  and  resulted  in  death  on  the  third  day.  The  microbe 
did  not  change  in  its  morphology  or  pathogenic  properties  after  passing 
through  a  series  of  inoculations.     Both  Ogston  and  Rosen  bach  are  of 

11 


162  PRINCIPLES   OF   SURGERT. 

the  opinion  that  the  chain  micrococcus  with  wliich  Koch  produced 
progressive  gangrene  in  the  field-mouse  is  identical  with  the  strepto- 
coccus pyogenes.  This  question  will  have  to  be  decided  by  future 
research,  which  must  have  for  its  object  the  isolation  and  cultivation  of 
the  chain  coccus  from  the  necrosed  tissues  of  the  field-mouse.  Baum- 
garten  is  of  the  opinion  that  microbes  can  produce  necrosis  not  only  b}' 
the  production  of  a  tissue  poison,  but  also  b3^  causing  decomposition  and 
by  the  assimilation  of  material  necessary  for  cell  nutrition.  The  expla- 
nation ndvanced  by  Koch  ten  years  ago,  however,  appears  more  rational : 
"  Introduced  by  inoculation  (chain  cocci)  into  living  animal  tissues,  thej^ 
multiply,  and  as  a  part  of  their  vegetative  process  they  excrete  soluble 
substances  which  get  into  the  surrounding  tissues  by  diffusion,  and 
when  greatly  concentrated,  as  in  the  neighborhood  of  the  micrococci, 
this  product  of  the  organisms  has  such  a  deleterious  action  on  the  cells 
that  these  perish  and  finally  disappear  completely.  At  a  greater  distance 
from  the  mici'ococci  the  poison  becomes  more  diluted  and  acts  less 
intensely,  only  producing  inflammation  and  accumulation  of  lymph- 
corpuscles.  Thus  it  happens  that  the  micrococci  are  always  found  in 
the  gangrenous  tissue,  and  that  in  extending  they  are  preceded  b}'  a  wall 
of  nuclei  which  constantly  melts  down  on  the  side  directed  toward 
them,  wiiile  on  the  opposite  side  it  is  as  constantly  renewed  by  lymph 
deposited  afresh." 

An  almost  identical  form  of  gangrene,  as  experimentally  produced 
in  the  field-mouse  by  Koch,  is  occasionally  met  with  in  man.  It  is 
known  as  progressive  gangrene,  and  is  so  called  from  its  most  conspicu- 
ous clinical  feature — rapid  extension.  Before  antiseptic  surgery  was 
known  it  frequently  developed  in  cases  of  compound  fracture  and  com- 
pound dislocation  of  large  joints,  and  often  proved  the  direct  cause  of 
loss  of  limb  or  life,  or  both.  Two  cases  came  under  my  own  observation 
where  it  occurred  after  extirpation  of  carcinoma  of  the  breast,  in  one 
without,  and  in  the  otlier  with,  removal  of  the  axillary  glands.  In  both 
cases  the  first  symptoms  appeared  on  the  third  day.  The  general 
symptoms  were  those  of  intense  sepsis,  while  the  local  conditions 
resembled  first  what  used  to  be  called  phlegmonous  erysipelas.  An 
erysipelatous  blush  appeared  at  the  margins  of  the  wound  and  extended 
rapidly  in  all  directions,  accompanied  by  infiltration  of  the  deep  tissues. 
The  gangrene  attacked  the  tissues  first  involved  and  followed  the  course 
of  the  phlegmonous  inflammation.  In  spite  of  the  most  energetic  local 
and  general  treatment,  both  patients  died  at  the  end  of  the  first  w^eek. 
Rosenbach  describes  two  cases  tlmt  came  under  his  care.  In  one  the 
disease  started  from  a  small  wound  of  a  finger,  the  process  finally 
extending  to  the  lower  extremities,  with  death  on  the  sixth  day.     In 


ETIOLOGY.  168 

the  second  case,  the  local  lesion  appeared  first  as  a  red  indumtiuii, 
around  which  cedema  developed  rapidl}-,  the  skin  covering  the  part 
presenting  a  reddish-blue  discoloration  before  gangrene  set  in.  Tills 
patient  had  an  eruption  of  the  skin  over  the  whole  surface  of  the  body 
which  resembled  the  rash  of  scarlatina.  From  the  lesions  of  both  of 
these  cases  Rosenbach  cultivated  npon  peptone-meat  gelatin  the  strepto- 
coccus pyogenes.  Ogston  calls  this  affection  erysipelatoid-wound  gan- 
grene,' and  always  found  in  the  gangrenous  tissue  the  streptococcus. 
Gangrene  produced  by  staphylococcus,  the  same  author  calls  sloughing 
inflammation  or  inflanimator}-  mortification.  Tiie  streptococcus  of 
erysipelas  never  produces  gangrene,  and  when  this  complication  occurs 
in  this  disease  it  is  always  a  positive  indication  that  secondary  infection 
with  pus-microbes  has  taken  place. 

Putrefactive  Bacteria. — Necrosis  occurring  from  the  action  of  anj^ 
other  microbes  than  those  of  putrefaction  is  not  attended  by  an}'  disa- 
greeable odor  or  other  evidences  of  putrefaction,  and,  if  limited  in  extent 
and  protected  against  the  invasion  of  saproph3'tes,  the  dead  tissue  may 
be  completel}^  removed  b}-  absorption.  Putrefactive  bacteria  feed  on 
dead  tissue,  and  in  the  absence  of  such  tlie}'  are  comparatively  harmless. 
Putrefaction  onh'  takes  place  in  moist  gangrene,  and  is  alwa3's  caused 
by  the  invasion  of  dead  tissue  with  one  or  more  species  of  saprophj'tes. 
Progressive  gangrene,  complicated  by  secondary  infection  with  sapro- 
phj'tes,  is  characterized  1)}'  the  formation  of  gases  which  give  rise  to 
emphysema.  Progressive  gangrene  with  emph3-sema  is  one  of  the  most 
fatal  of  all  wound  complications,  as  the  ptomaines  elaborated  by  the 
saprophytic  bacilli  greatly  increase  the  danger  from  sepsis.  Sulphuretted 
hydrogen  is  one  of  the  gases  formed  during  putrefaction  of  necrosed 
tissue.  Rosenbach  cultivated  from  the  infected  tissues,  in  2  cases  of 
progressive  gangrene  with  emphj'sema,  a  saproph^'tic  bacillus  with 
spores.  Hauser  cultivated  from  putrefying  organic  substances  one  or 
more  kinds  of  the  jorote us,  Wxe  proteus  mirabilis  {Zenkeri)  and  vulgaris. 

Trauma. — The  vitality  of  a  part  is  completelj'-  destroj^ed  if  a  trauma 
is  sufficient  in  intensity  to  arrest  the  circulation  completel}^  and  of  such 
a  character  and  extent  as  to  render  a  return  of  it  impossible.  Such 
injuries,  for  instance,  ai'e  caused  b}'  the  passage  of  a  car-wheel  over  a 
limb,  wdiere  the  skin  often  remains  intact,  while  all  of  the  deeper  tissues 
are  completel}''  crushed.  A  blow  against  a  part  of  the  bod^'  where  only 
a  thin  la^'er  of  tissue  is  interposed  between  the  skin  and  an  underlying 
bone  may  crush  the  subcutaneous  tissue  to  such  an  extent  as  to  preclude 
the  possibilit}'  of  a  return  of  an  adequate  circulation,  and  ncrosis  follows 
as  an  inevitable  result.  Deep-seated  contusions  from  the  application  of 
external  violence  are  often  attended  by  circulatory  disturbances,  which 


164  PRINCIPLES    OF    SURGERY. 

necessarily  result  in  necrosis.  Necrosis  of  ganglion-cells  following  con- 
tusion of  the  brain  affords  a  good  illustration  of  the  occurrence  of 
traumatic  necrosis  at  a  distance  from  where  tlie  force  was  applied.  In 
such  cases  the  cells  are  separated  from  all  tlieir  anatomical  connections 
by  the  trauma,  and  either  undergo  calcification  or  are  removed  by  at)- 
sorption.  If  such  a  contused  area  become  the  scat  of  a  subsequent 
infection,  suppuration  or  putrefaction  can  occur,  according  to  the  location 
of  the  part  injured,  infection  taking  place  Avith  pyogenic  microbes  or 
saprophytes.  In  the  so-called  railway-spine  the  cell  necrosis  following  a 
contusion  of  the  spinal  cord  leads  to  remote,  central,  and  peripheral 
disturbances.  A  trauma  may  be  of  such  a  nature  as  to  inflict  an  injury 
not  incompatible  with  the  integrity  of  a  limb,  but  may  create  conditions 
which  subsequently  result  in  complete  obliteration  of  a  main  artery.  If 
an  arter}'  is  subjected  to  serious  i)ressure  or  traction,  tlie  intima  gives 
way  and  its  lumen  is  subsequentl3'  obliterated  by  tlie  formation  of  a 
thrombus  at  the  seat  of  injury.  In  such  a  case  the  artery  is  at  first  per- 
meable, and  the  distal  pulsations  are  unaffected  until  the  lumen  of  the 
vessel  is  narrowed  and  finally  completely'  obliterated  by  the  formation 
of  a  thrombus.  Professor  von  Wahl  has  called  attention  to  an  early  and 
important  symptom  in  these  cases,  the  detection  of  which  enables  the 
surgeon  to  recognize  the  vessel  injury  before  the  appearance  of  the 
positive  peripheral  symptoms,  viz.,  a  hruit^  which  can  be  heard  by 
placing  the  stethoscope  over  the  seat  of  injury.  The  vessel  injury  in 
such  cases  is  of  serious  import,  as  the  contusion  of  the  soft  tissues 
which  is  usuall}''  also  present  retards  or  prevents  the  formation  of  an 
adequate  collateral  circulation,  and  gangrene  occurs  in  consequence  of 
complete  interruption  of  the  arterial  circulation.  A  vein  may  be  injured 
in  a  similar  manner,  and  the  venous  stasis  following  obliteration  by  a 
thrombus  may  become  a  determining  cause  of  gangrene  of  a  limb,  the 
vitalitj'^  of  which  has  been  otherwise  impaired  by  the  injury. 

Decubitus. — Prolonged  uninterrupted  pressure  causes  necrosis  by 
interrupting  the  circulation.  Tight  bandaging  and  pressure  of  splints 
have  often  been  productive  of  gangrene.  Bed-sores  are  liable  to  form  in 
patients  suffering  from  acute  infectious  diseases,  and  in  persons  suffering 
from  fracture  of  the  spine,  or  disease  of  the  spinal  cord  ;  also,  in  aged  obese 
persons  treated  in  the  recumbent  dorsal  position  for  fracture  of  the  neck  of 
the  femur.  Decubitus  is  most  prone  to  appear  in  consequence  of  pressure 
over  bony  prominences,  and  on  this  account  we  look  for  it  in  persons 
who  are  going  through  a  long-enforced  confinement  in  bed,  first  over  the 
sacrum,  the  trochanteric  regions,  the  spinous  processes  of  the  vertebrae, 
and  the  heels,  parts  most  affected  by  the  dorsal  decubitus.  The  deleteri- 
ous effect  of  pressure  is  greatly  aggraA-ated  by  filthj''  surroundings,  as 


ETIOLOGY.  165 

under  these  circumstances  the  necrosed  tissue  becomes  the  seat  of  infec- 
tion ■with  pus-microbes  and  saprophytic  bacteria,  -which  inaugurate  a 
progressive  gangrene  and  sepsis,  often  constituting  the  direct  cause  of 
death.  It  is  not  unusual,  in  cases  of  septic  decubitus,  to  find  the  whole 
sacrum  exposed,  and  in  one  instance  that  came  under  the  author's  obser- 
vation the  spinal  canal  was  opened  and  through  the  opening  the  cerebro- 
spinal fluid  escaped,  first  clear,  later  purulent.  This  patient  lived  for 
several  daj-s  after  the  cerebro-spinal  fluid  had  commenced  to  escape,  and 
before  his  deatli  he  presented  s^-mptoms  which  indicated  that  the  menin- 
gitis had  extended  to  the  envelopes  of  the  brain. 

Defective  Arterial  Blood-Supply. — The  aseptic  ligature,  combined 
with  the  antiseptic  treatment  of  wounds,  has  been  the  means  of  greatly 
diminishing  the  freqnenc}'  of  gangrene  after  ligation  of  the  principal 
arteries  of  a  limb  in  their  continuity.  Gangrene  usuall}'  occurred,  not 
so  much  from  the  sudden  interruption  of  the  arterial  blood-supply  as 
from  the  septic  inflammation  following  the  operation,  which  interfered 
with  the  formation  of  a  satisfactory  collateral  circulation. 

Ligation  of  Arteries  in  their  Continuity. — Statistics  of  a  number  of 
years  ago  show  tiiat  gangrene  has  followed  ligation  of  the  subclavian  in 
the  outer  third  iu  9  per  cent,  of  the  cases  reported;  external  iliac,  15 
percent.;  common  femoral,  11  per  cent.  The  results  after  ligation  of 
these  vessels  have  much  improved  since  the  introduction  of  the  aseptic 
ligature.  In  a  healthy  person  witli  normal  blood-vessels  there  is  but 
little  danger  of  gangrene  following  the  ligation  of  the  principal  arteries 
of  a  limb  with  an  aseptic  ligature  under  antiseptic  precautions.  Gradual 
obliteration  of  an  artery  by  a  thrombus  is  not  attended  by  equal  danger 
of  the  occurrence  of  gangrene  as  when  the  same  vessel  is  suddenlj'  and 
completely  blocked  by  impaction  from  the  arrest  of  an  embolus,  because 
circulation  is  on  a  fair  way  of  becoming  established  before  the  lumen  of 
the  vessel  is  completely  closed,  while  in  the  latter  case  the  demand  on 
the  collateral  vessels  is  more  urgent  and  sudden,  and  consequenth*  the 
failure  on  their  part  to  act  as  substitutes  for  the  obliterated  trunk  is 
more  frequent.  Valvular  disease  of  the  heart,  fatt^^  degeneration  of  this 
organ,  atheroma  of  the  arteries, — in  fact,  all  pathological  conditions 
which  diminish  the  vis  a  tergo  are  instrumental  in  the  causation  of  gan- 
grene, when  from  any  accidental  cause  or  oj^erative  interference  the 
blood-supply  to  a  limb  lias  been  diminished,  or  when  the  tissues  are  the 
seat  of  a  progressive  septic  inflammation.  Gradual  diminution  of  the 
arterial  blood-supply  general!}'  gives  rise  to  drv  gangrene,  as  is  the  case 
in  senile  gangrene,  Avhile  sudden  interruption  of  tlie  circulation  through 
a  lai'ge  arter\'  from  the  application  of  a  ligature  or  the  impaction  of  an 
embolus  is  usually  followed  b}-  moist  gangrene. 


166  PRINCIPLES   OF    SURGERY. 

Obstructed  Venous  Circulation. — Impeded  venous  circulation  is 
fraught  with  as  much  danger,  as  far  as  the  production  of  gangrene  is 
concerned,  as  obstruction  of  the  arterial  circulation.  Langenbeck  was 
impressed  with  this  fixct  so  strongly  that  he  recommended,  if  it  became 
necessary  to  ligate  one  of  the  principal  veins  of  an  extremity  near  the 
trunk,  to  ligate  at  the  same  time  the  accompanying  artery  in  order  to 
guard  against  the  evil  results  following  ligation  of  a  large  vessel.  Anti- 
septic surgery  has  minimized  the  danger  of  ligaturing,  for  instance,  the 
axillary  or  femoral  vein,  and  no  surgeon  at  the  present  time  would  deem 
it  necessary,  or  even  justifiable,  to  ligate  the  corresponding  arteries 
simply  for  the  purpose  of  preventing  excessive  venous  engorgement  and 
of  favoring  the  formation  of  an  adequate  venous  collateral  circulation. 
The  same  advantages  which  have  resulted  from  antiseptic  operations  for 
the  timely  formation  of  an  arterial  collateral  circulation  after  ligature  of 
an  arter}'  are  secured  for  the  maintenance  of  an  inadequate  venous  cir- 
culation after  the  ligation  of  a  vein.  Venous  obstruction  from  patho- 
logical causes  often  proves  more  disastrous,  as  the  causes  which  have 
brought  about  the  formation  of  a  thrombus  frequently  do  not  remain 
local,  and  the  thrombus  increases  in  length  in  both  directions,  thus 
rendering  the  formation  of  a  collateral  circulation  a  difficult,  if  not  an 
impossible,  occurrence.  As  venous  obstruction  gives  rise  to  oedema 
gangrene,  if  it  occur  under  these  conditions,  it  always  represents  the 
moist  variety,  and  is  usually  accompanied  by  putrefaction. 

Heat. — Heat  produces  pathological  conditions  according  to  the  de- 
gree of  the  temperature  and  the  length  of  time  a  part  is  exposed  to  its 
action.  A  momentar}'  exposure  even  to  a  high  temperature  produces 
only  a  burn  of  the  first  degree ;  that  is,  simply  an  active  hyperemia  and 
redness  of  the  surface.  If  the  part  is  exposed  for  a  somewhat  longer 
time  the  hyperaemia  is  followed  by  a  superficial  inflammation  and  blis- 
ters form, — a  condition  w^hich  is  described  as  a  burn  of  the  second  degree. 
In  such  cases  the  necrosis  is  limited  to  the  epidermis,  which  is  detached 
from  the  papillary  layer.  In  burns  of  the  third  degree  the  deeper  tis- 
sues are  destroyed  by  tlie  heat,  and  extensive  necrosis  is  the  result. 
Cohnheim  determined  that  a  temperature  from  54°  to  58°  C.  was  sufficient 
to  produce  gangrene  in  the  rabbit's  ear.  If  he  immersed  the  ear  for  a 
short  time  in  water  heated  to  this  temperature,  necrosis  always  followed. 
A  somewhat  lower  temperature  continued  for  a  longer  time  produced  the 
same  eflfect.  Heat  produces  necrosis  by  coagulating  the  cell-protoplasm, 
if  its  action  is  superficial ;  if  it  penetrate  more  deepl}',  the  blood  in  the 
blood-vessels  is  coagulated,  and  necrosis  of  the  tissues  deprived  of 
circulation  in  this  manner  follows  as  an  inevitable  result.  Intestinal 
ulceration,  in  case  of  extensive  burns,  is  also  a  necrotic  process,  caused 


ETIOLOGY.  167 

b}'  capillary  obstruction  with  dead  or  dying  blood-corpuscles  derived 
from  the  burned  district.  It  has  been  found  experimentally  that  a 
temperature  over  45°  C.  has  a  destructive  effect  on  the  blood-corpuscles. 
Welti  ascertained  that  if  the  ear  of  a  rabbit  is  kept  immersed  in 
water,  gradually  heated  to  70°  C,  bleeding  from  the  nose  and  hsemo- 
globinurea  followed, — symptoms  which  he  attributed  to  partial  or 
complete  obstruction  of  capillary  vessels  with  the  third  corpuscle  of  the 
blood. 

Cold. — The  action  of  cold  in  producing  necrosis  is  closely  allied  to 
that  of  heat.  Frost-bites  are  classified  the  same  as  burns.  Cold,  like 
heat,  causes  gangrene  by  producing  by  its  action  cell  necrosis  and  vas- 
cular obstruction. 

Cohnheim  produced  gangrene  of  the  rabbit's  ear  by  exposing  it 
for  a  short  time  to  a  temperature  of  16°  C.  The  length  of  time  a 
part  is  exposed,  either  to  heat  or  cold,  exerts  an  important  influeuce 
in  determining  the  extent  and  depth  of  the  subsequent  gangrene. 
Gangrene  resulting  from  a  burn  or  exposure  to  cold  remains  dry  and 
aseptic  as  long  as  the  entrance  from  without  of  pus-microbes  and  sapro- 
phytes is  prevented,  but  with  microbic  invasion  suppuration  and  putre- 
faction are  established. 

Caustics. — Chemical  substances  which  by  their  local  action  on  the 
tissues  produce  extensive  cell  necrosis  are  called  caustics.  Of  these  the 
strong  acids  and  mineral  salts  destroy  cells  by  causing  coagulation. 
The  necrosed  tissue,  or  eschar,  resulting  from  their  action  is  firm,  and 
the  contour  of  the  cells  is  well  preserved.  The  alkaline  caustics,  on  the 
other  hand,  dissolve  the  tissue  elements,  and  the  slough  resulting  from 
their  application  is  soft.  A  peculiar  form  of  necrosis  of  the  maxillary 
bones  occurs  in  persons  exposed  to  the  fumes  of  phosphorus.  The  most 
recent  explanation  of  the  occurrence  of  necrosis  of  the  jaws  in  persons 
employed  in  match-factories  is  to  the  effect  that  the  phosphorus  fumes 
in  the  mouth  are  transformed  into  phosphoric  acid,  and  that  necrosis  of 
the  bone  is  produced  by  the  direct  action  of  the  acid  on  tlie  bone  and 
myeloid  cells,  while  the  periosteum  remains  intact  and  produces  new 
bone. 

Ergot. — The  prolonged  administration  of  ergot  in  large  doses  is 
attended  by  the  risk  of  causing  gangrene.  The  gangrene  from  ergotism 
is  alwa^'s  of  the  dry  variety.  It  is  generally  believed  that  it  is  caused 
by  the  drug  keeping  up  an  angio-spasm,  which  shuts  off  the  full  blood- 
supply  to  the  peripheral  portion  of  the  extremities, — the  most  frequent 
seat  of  the  gangrene.  Zweifel,  of  Erlangen,  believes  that  the  toxic  effect 
of  ergot  results  in  a  vasomotor  paresis,  and  that  the  gangrene  is  due  to 
defective  innervation. 


168  PRINCIPLES    OF    SURGERY. 

SYMPTOMS. 

Internal  Necrosis. — In  simple  cell  necrosis  the  tissue  elements  may- 
have  luulergoue  no  clianges  in  form,  but  the  cell-protoplasm  has  lost  its 
vital  properties,  and  function  has  been  completely  arrested.  Such  cells 
present  a  cloudy  a[)pearance,  and  if  the  necrosis  has  resulted  from  a 
gradual  or  sudden  ischtiemia  the  part  affected  presents  a  pale  appearance. 
In  the  periphery  of  such  a  necrotic  area  the  vessels  become  dilated  and 
a  hyperreniic  zone  forms,  in  which  the  collateral  circulation  is  to  be 
establislu'd.  If  an  artery  in  any  of  the  internal  organs  is  suddenly' 
obliterated  b3'  the  impaction  of  an  embolus,  the  tissues  supplied  by  the 
closed  vessels  are  deprived  for  a  time,  and  perhaps  permanently,  of  their 
blood-supply,  and  in  consequence  of  this  they  become  pale,  while  around 
the  wedge-shaped,  aufemic  territory  the  vessels  concerned  in  the  forma- 
tion of  collateral  circulation  are  distended  to  their  utmost,  and  often 
yield  to  the  increased  intra- vascular  pressure  when  extravasation  of  blood 
occurs.  If  the  collateral  circulation  is  not  speedily  establisiied, necrosis 
of  the  tissues  supplied  by  the  obliterated  vessel  is  the  result.  In  mycotic 
cell  necrosis  karyolysis — that  is,  dissolution  of  the  cells — usually  occurs. 
If  the  cell-membrane  rupture  and  the  contents  of  the  cell  escape,  we 
speak  of  a  karyorhexis.  Absolute  ischsemia  of  certain  parts  or  cell 
territories  continued  for  only  one  to  two  hours  is  sure  to  result  in 
necrosis.  If  any  portion  of  the  In'ain,  intestines,  or  kidney  is  deprived 
of  blood-supply  for  this  period  of  time,  nutrition  is  completely  sus- 
pended, and  cell  necrosis  follows  as  an  inevitable  consequence.  Litten 
ligated  the  renal  arter}'  in  animals,  and  found,  at  the  end  of  an  hour  and 
a  half  to  two  hours,  the  renal  epithelia  in  a  state  of  necrosis.  Limited 
necrosis  of  the  parenchyma  of  the  brain  may  give  rise  to  focal  symptoms 
by  which  the  lesion  can  not  only  be  recognized,  but  often  accurately 
located.  Infarcts  of  the  kidney  can  frequently  be  diagnosticated  by  a 
careful  chemical  and  microscopical  examination  of  the  urine.  A  similar 
condition  in  the  lungs  gives  rise  to  circumscribed  catarrhal  pneumonia, 
which  can  be  recognized  by  a  careful  physical  examination  of  the  chest. 
Ulcer  of  the  stomach,  the  result  of  a  circumscribed  necrosis,  is  attended 
by  a  complexus  of  symptoms  pointing  directly  to  the  seat  and  nature  of 
the  lesion.  Necrosis  in  internal  organs  is  seldom  followed  by  putrefac- 
tion, as  saprophytes  seldom  reach  the  dead  tissue.  Necrosis  of  the  lungs 
is  sometimes  followed  by  gangrene,  by  the  entrance  into  the  necrosed 
tissue  of  putrefactive  bacteria  from  the  respiratory  passage. 

Gangrene  of  External  Parts. — As  it  is  often  impossible  to  recognize 
during  life  a  limited  cell  necrosis  in  the  internal  organs  by  the  symptoms 
presented,  this  subject  has  been  briefly  disposed  of,  but  the  s3^mptoma- 
tology  of  external  gangrene  will  receive  a  more  thorough  consideration. 


SYMPTOMS.  169 

It  might  appear  that  the  recognition  of  the  existence  of  gangrene  of  any 
of  the  external  parts  would  require  no  special  care  or  erudition.  But  this 
is  not  so.  It  is  true  that  when  gangrene  is  fully  developed,  when  all  the 
characteristic  symptoms  are  present,  a  correct  diagnosis  can  be  made  on 
first  sight.  But  cases  occur  where  it  is  exceedingly  difficult  to  determine 
whether  the  part  affected  is  dead  or  onlj-  in  a  state  of  inflammation.  In 
illustration  of  this  the  author  will  onlj^  allude  to  the  difficulties  which 
surround  the  surgeon  in  many  cases  of  herniotomy,  when  he  has  to 
determine  whether  it  is  justifiable  to  return  a  portion  of  intestine  that 
has  been  strangulated  for  some  time  if  he  simply  relies  on  the  appearance 
of  the  intestine.  The  intestine  presents  a  duskj^,  almost  black  appear- 
ance, and  the  casual  observer  might  come  to  the  conclusion  that  it  is 
gangrenous,  and  treat  it  as  such,  when,  in  fact,  a  more  careful  obser- 
vation will  soon  reveal  the  fact  that  the  circulation  is  not  completely 
arrested,  and  that  it  is  safe  to  return  it. 

(a)  Pain. — Sudden,  severe,  often  excruciating  pain  in  a  limb  is  the 
first  indication  which  announces  the  occurrence  of  embolism  in  one  of 
the  large  arteries.  In  the  lower  extremit}'  the  embolus  is  often  arrested 
at  the  bifurcation  of  the  poi)liteal  arterj',  but  the  pain  extends  along  the 
whole  limb,  from  the  toes  to  the  groin.  The  sudden  anaemia  is  the  cause 
of  the  pain.  In  senile  gangrene  the  gradual  ischaemia  caused  by  the 
atheromatous  degeneration  of  the  arteries  gives  rise  to  pain  and  a  sen- 
sation of  numbness,  which  precede  the  gangrene  for  weeks  or  months. 
Acute  inflammation  resulting  in  gangrene  is  attended  by  intense  pain 
from  the  very  beginning;  the  pain  abates,  as  a  rule,  with  the  occurrence 
of  gano;rene.  Pain  may  be  absent  at  the  seat  of  necrosis,  and  referred 
to  some  other  part  or  locality.  In  strangulated  hernia  the  patient  often 
sufl'ers  little  or  no  pain  at  all  in  the  swelling,  but  complains  of  a  period- 
ical pain  in  the  region  of  the  umbilicus.  The  absence  of  pain  and 
tenderness  over  the  region  of  a  hernia  speaks  rather  for  than  against  the 
presence  of  gangrene.  Osteomyelitis  is  attended  by  severe  pain,  which 
is  diminished  or  subsides  with  the  escape  of  the  products  of  inflamma- 
tion from  the  bone  into  the  surrounding  tissues.  In  cases  of  intestinal 
obstruction  the  cessation  of  pain,  with  continuance  of  the  sj-mptoms  of 
obstruction,  is  an  indication  that  gangrene  has  occurred. 

(b)  Tenderness. — The  pain  elicited  by  pressure  is  a  more  important 
symptom  in  the  diagnosis  of  necrosis  than  spontaneous  pain.  As  long 
as  the  part  suspected  to  be  necrotic  is  sensitive  to  the  touch  it  is  a  sign 
that  necrosis  has  not  taken  place.  To  test  the  sensation  of  a  part  it  is 
advisable  to  resort  to  puncture  with  an  aseptic  needle.  Absence  of  pain 
and  all  sensation  on  puncturing  the  tissues  with  a  needle  is  often  the  best 
argument  to  convince  the  patient  and  friends  that  necrosis  has  occurred. 


170  PRINCIPLES   OF    SURGERY. 

(c)  Temperature. — The  difference  in  the  temperature  of  a  part 
threatened  with  gangrene  has  given  rise  to  the  expressions  hot  and  cold 
gangrene.  If  gangrene  follow  an  acute  inflammation,  the  local  tempera- 
ture remains  high  until  other  evidences  of  gangrene  make  their  appear- 
ance, when  the  complete  arrest  of  circulation  and  tissue  metamorphosis 
result  in  a  sudden  fall  of  the  local  temperature.  In  gangrene  following 
atheroma,  tlirombosis,  embolism,  and  ligation  of  arteries  the  local 
temperature  is  reduced  before  gangrene  occurs. 

(d)  Pulse. — After  ligation  of  the  principal  artery  of  a  limb  the  sur- 
geon examines  anxiously  from  day  to  day  for  the  appearance  of  pulsa- 
tion in  the  distal  portion  of  the  arter}', — an  occurrence  upon  which 
depends  the  fate  of  the  limb.  The  re-appearance  of  the  pulsation  in  the 
distal  part  of  the  artery  is  a  certain  indication  that  collateral  circulation 
has  become  established,  and  that  gangrene  will  not  occur.  With  the  ap- 
pearance of  distal  pulsations  the  local  temperature  increases,  and  the 
diminished  tissue  metamorphosis  is  restored  to  its  normal  state.  In  em- 
bolism or  thrombosis  of  a  large  artery,  the  same  disturbances  in  the 
peripheral  circulation  of  the  limb  are  observed  as  after  ligation.  By 
searching  for  pulsation  in  different  parts  of  the  limb  the  surgeon  can 
often  locate  the  thrombus  or  embolus.  If,  for  instance,  the  embolus  or 
thrombus  is  located  in  the  terminal  portion  of  the  popliteal  artery,  pulsa- 
tions of  the  femoral  artery  can  be  felt  from  Poupart's  ligament  down  to 
the  seat  of  obstruction,  while  no  pulsations  below  this  point  can  be  felt 
until  collateral  circulation  is  established.  Obliteration  of  an  artery  from 
patliological  causes  is  prone  to  prevent  the  formation  of  an  adequate 
collateral  circulation  by  the  growth,  in  both  directions,  of  the  thrombus 
or  embolus.  The  pulse  furnishes  the  most  important  means  to  follow 
from  day  to  day  the  growth  of  the  intra-vascular  blood-clot.  In  senile 
gangrene  a  thrombus  frequently  forms  in  one  of  the  smallest  arteries 
and  grows  in  a  proximal  direction,  extending  from  the  digital  branches 
to  the  dorsalis  pedis,  to  the  anterior  tibial,  or  from  the  plantar  arteries  to 
the  posterior  tibial,  the  popliteal,  and  finally  the  femoral.  In  such  cases 
the  arteries  can  be  felt  as  firm  cords,  but  pulsations  are  limited  to  the 
previous  portion  of  the  vessels.  An  embolus  often  becomes  the  centre 
of  an  enormous  thrombus,  which  seriously  impairs  the  chances  of  pres- 
ervation of  the  limb  by  the  establishment  of  an  early  and  adequate  col- 
lateral circulation.  If  an  embolus  obstruct  the  popliteal  artery,  pulsa- 
tions can  ])e  felt  above  this  point,  but  the}'  disappear  with  the  extension 
of  the  secondar\'  thrombus  in  a  proximal  direction. 

(e)  Swelling. — In  moist  gangrene  the  necrosed  tissue  imbibes  moist- 
ure to  a  considerable  extent,  and  the  slough  is  larger  than  the  tissue  it 
represents.     The  swelling  is  twice  more  increased  if  gas  forms  in  the 


SYMPTOMS.  171 

tissues.  In  dry  gangrene  the  parts  shrink,  become  firmer,  and  instead 
of  swelling  there  is  diminution  in  their  size  as  compared  with  their 
volume  in  a  normal  condition. 

(f)  Emphysema. — The  presence  of  emph3\sema  in  gangrenous  tissue 
is  a  certain  indication  of  the  presence  of  gasogenic  bacteria.  The  char- 
acter of  putrefaction  depends  on  the  kind  of  saprophytes  which  are 
present  in  the  dead  tissues.  The  different  kinds  of  proteus  possess  gas- 
producing  properties.  The  proteus,  according  to  Hauser,  appears  in  dif- 
ferent forms,  according  to  the  chemical  reaction  of  the  soil  upon  which  it 
grows.  On  acid  gelatin  the  culture  consists  of  cocci  and  short  bacilli ; 
on  alkaline  gelatin  it  grows  in  the  form  of  threads,  vibrios,  spirilli,  etc. 
All  these  different  forms  of  proteus  growing  in  dead  tissue  exposed  to 
the  atmospheric  air  produce  sulphuretted  hydrogen.  Hauser  cultivated 
the  proteus  from  ulcerating  carcinomas  and  bed-sores.  In  the  cases  of 
progressive  gangrene  with  emphysema  examined  bacteriologically  hy 
Roseubach,  he  found  the  bacillus  saprogenes.  Emph3'sema  is  sometimes 
so  marked  that  on  percussion  a  tympanitic  resonance  is  elicited.  When 
less  in  degree  its  presence  can  be  readily  recognized  by  pressure,  which 
causes  a  crackling,  crepitating  sound. 

(g)  Color. — If  gangrene  take  place  in  consequence  of  interrupted 
arterial  circulation,  the  part  at  first  presents  a  preternaturally  pale  ap- 
l)earance  until  the  first  visible  evidences  of  the  actual  occurrence  of 
gangrene  are  announced  by  a  livid  or  lead  color,  at  a  point  where  the 
circulation  has  first  been  completelj'  arrested.  The  lividity,  when  it  is 
due  to  complete,  irreparable  capillary  stasis,  is  not  affected  by  pressure. 
Blisters  containing  a  sanious  fluid  form  at  points  where  the  deeper  tissues 
have  already  undergone  necrosis.  As  soon  as  the  circulation  has  been 
completely  arrested,  tissue  metamorphosis  is  at  once  suspended,  and  the 
further  changes  are  entirely  of  a  chemical  nature.  The  colored  corpus- 
cles of  the  blood  undergo  rapid  disintegration ;  the  coloring  material  is 
diftused  through  the  dead  tissue  and  into  the  interior  of  the  bullae.  The 
black  color  of  gangrenous  tissue  is  produced  by  sulphuret  of  iron, — a 
combination  of  sulphuretted  hydrogen  and  hoemoglobin. 

(h)  Condition  of  Tissues. — The  condition  of  the  dead  tissues  will  de- 
pend on  the  cause  of  the  necrosis.  In  dry  gangrene  they  become  firmer 
hj  evaporation  of  the  fluids.  In  moist  gangrene  they  imbibe  fluids  and 
undergo  maceration,  becoming  soft  and  friable.  A  fetid,  sanious  fluid 
escapes  from  the  dead  tissue.  Adipose  tissue  in  a  condition  of  gangrene 
undergoes  speedy  disintegration,  and  free  globules  of  fat  are  mixed  with 
the  sanious  discliarge.  Maceration  of  tissue  is  considered  by  Ravoth  as 
tlie  most  important  condition  in  determining  the  pi'esence  of  gangrene  in 
cases  of  strangulated  hernia.     He  maintains  that  if  the  tissues  of  the 


172  PRINCIPLES   OF   SURGERY. 

intestinal  wall  can  be  readily  separated  and  teased  asunder  with  a  dis- 
secting  forceps  there  can  be  no  doubt  that  gangrene  has  occurred.  This 
maceration, however, takes  place  only  some  time  after  the  circulation  has 
ceased,  and  is  entire!}^  absent  in  necrosis  of  bone,  cartilage,  and  tissues 
well  supplied  witli  elastic  elements,  as  the  arteries.  In  determining  tlie 
presence  of  gangrene  in  strangulated  hernia,  where  any  doubt  as  to  its 
presence  exists  in  the  mind  of  the  operator,  it  is  much  better  to  liberate 
the  strangulated  gut,  draw  it  forward  and  irrigate  it  every  few  minutes 
with  a  hot  solution  of  boracic  acid,  wliich  will  stimulate  the  sluggish  cir- 
culation, and  will  soon  furnish  reliable  proof  of  the  actual  condition  of 
the  vessels  and  the  tissues.  Mechanical  stimulation  of  the  intestinal 
wall  is  also  a  valuable  diagnostic  measure,  as,  if  gangrene  has  occurred, 
no  amount  of  irritation  Avill  excite  peristaltic  action,  while  with  the 
restoration  of  the  impeded  circulation  the  muscular  fibres  will  respond 
to  irritation. 

(i)  OdoP. — Necrosed  tissue  does  not  emit  any  unpleasant  odor 
unless  it  has  become  invaded  with  putrefactive  bacteria.  The  almost 
unbearable  stench  which  attends  extensive  moist  gangrene  is  always  the 
result  of  putrefactive  changes.  Dry  gangrene  is  odorless.  In  acute 
inflammatory  affections  of  the  lung,  where  a  communication  has  been 
established  between  the  inflammatory  focus  and  the  bronchial  tubes,  the 
presence  or  absence  of  fostor  is  of  great  diagnostic  value,  as  its  presence 
speaks  in  favor  of  gangrene  and  its  absence  indicates  an  abscess. 

(j)  Mummification. — By  this  term  we  mean  a  drying  up  of  a  gan- 
grenous soft  part  iroui  the  loss  of  fluids  which  it  contains  by  evapora- 
tion. It  is  a  state  of  preservation  of  dead  tissue  while  still  attached  to 
the  living  body.  It  can  onlj-  occur  if  the  dead  tissue  is  exposed  to  the 
atmospheric  air,  and  on  this  account  it  is  always  absent  in  necrosis  of 
internal  organs.  Mummification  can  only  take  place  where  putrefaction 
is  absent,  and,  therefore,  is  most  frequently  met  with  where  gangrene  is 
first  limited,  and  increases  gradually  by  an  aggregation  of  the  causes 
which  produce  gradual  diminutian  of  the  arterial  blood-supi)ly,  as  in 
cases  of  senile  gangrene. 

(k)  Line  of  Demarcation. — The  line  of  demarcation  is  the  line  where 
the  further  extension  of  gangrene  has  been  arrested  by  an  adequate  col- 
lateral circulation  and  a  wall  of  living  granulations.  Back  of  this  line 
of  demarcation,  on  the  side  of  the  living  tissues,  there  is  to  be  found  a 
hyperaemic  zone,  which  precedes  and  attends  the  regenerative  process, 
and  by  which  the  further  extension  of  the  gangrene  is  prevented.  In 
septic  gangrene  the  line  of  demarcation  marks  the  limits  of  the  area 
of  "infection,  while  in  aseptic  gangrene  it  indicates  the  point  where  the 
vascular  conditions  answer  the  physiological  requirements  of  the  part. 


SYMPTOMS.  173 

(I)  Elimination  of  Gangrenous  Part. — Spontaneous  elimination  of  a 
gangrenous  part  is  of  frequent  occurrence.  Tlie  necrotic  tissue  may  be 
disposed  of  in  a  spontaneous  cure  in  tliree  different  ways :  1.  Absorption 
of  dead  tissue.  2.  Separation  of  necrosed  part  b}'  granulation.  3. 
Separation  of  the  sphacelus  or  sequestrum  by  suppuration.  A  limited 
quantity''  of  necrosed  aseptic  tissue  can  be  completely  removed  by  ab- 
sorption in  the  same  manner  as  absorbable  aseptic  substances  are  re- 
moved when  implanted  in  the  tissues.  This  is  the  most  desirable 
termination  of  gangrene,  and  takes  place  frequenth'  in  cell  necrosis  of 
the  internal  organs.  Such  a  disposal  of  aseptic  necrosed  tissue  is  also 
possible  on  the  surface  of  the  skin  when  the  area  does  not  exceed  a 
square  inch,  and  an  aseptic  condition  is  secured  throughout.  The 
capacit}^  of  the  tissues  to  remove  aseptic  necrosed  tissue  is  limited,  and 
when  the  quantity  of  tissue  surpasses  this  capacity  the  dead  part  is  con- 
siderabl}'  diminished  in  size,  and  the  balance  is  detached  b}'  the  granula- 
tions which  form  at  the  line  of  demarcation,  and  is  finally  eliminated 
spontaneously  or  by  operation.  Repair  after  this  manner  of  elimination 
is  rapid  and  satisfactorj*.  If  infection  with  pus-microbes  has  taken 
place  in  the  beginning  of  the  lesion  which  has  caused  tlie  necrosis,  or, 
later,  at  the  line  of  demarcation,  separation  of  the  slough  takes  place  by 
means  of  a  suppurative  inflammation.  In  such  cases  the  dead  part  is 
not  diminished  in  size,  and  the  healing,  after  its  elimination,  takes  place 
more  slowlj'^,  and  the  result,  as  a  rule,  is  less  satisfactory.  Separation 
takes  place  ver}-  slowlj'  in  necrosis  of  bones,  intermuscular  connective 
tissue,  and  tendons,  requiring  often  weeks  and  months  before  the  dead 
tissue  can  be  removed, 

(m)  Liquefaction  of  Necrosed  Tissue. — Where  no  putrefaction  or 
suppuration  takes  place,  and  the  amount  of  necrosed  tissue  exceeds  the 
absorptive  capacity  of  the  surrounding  tissues,  liquefaction  takes  place, 
and  months  and  3'ears  later  the  seat  of  necrosis  is  occupied  by  what 
appears,  and  has  often  been  falsel}^  described,  as  a  cj^st.  This  method 
of  disposing  of  the  dead  tissue  is  observed  most  ft-equentl}^  in  organs 
scantil}'  supplied  with  connective  tissue,  as  the  brain  and  spinal  cord 
and  in  adipose  tissue. 

(n)  Encapsulation. — A  limited  area  of  aseptic  necrosed  tissue,  not 
amenable  to  absorption,  is  often  rendered  harmless  b}'  encapsulation. 
The  surrounding  living  tissue  throws  out  a  wall  of  granulation  tissue 
which  is  converted  into  connective  tissue,  forming  a  capsule  around  the 
dead  tissue.  This  method  of  disposal  of  dead  tissue  frequentlj^  occurs 
in  the  internal  organs.  A  sequestrum  occasionallj'  becomes  encapsulated 
after  the  interior  of  an  involucrum  has  been  rendered  spontaneously,  or 
by  treatment,  aseptic. 


174  PRINCIPLKS    OF    SURGERY. 

(o)  General  Symptoms. — These  will  have  reference  to  the  loss  of 
function  caused  by  cell  necrosis  in  internal  organs  and  sepsis  in  external 
necrosis.  Function  will  be  affected  according  to  the  location  and  extent 
of  cell  necrosis.  If  cell  necrosis  is  of  mj^cotic  origin  and  general  it  fre- 
quently becomes  a  direct  cause  of  death.  If  it  is  limited  to  a  single 
organ  the  symptoms  will  point  to  it  as  the  seat  of  the  disease.  Limited 
areas  of  cell  necrosis,  in  most  of  the  organs,  may  give  rise  to  ill-defined 
or  no  symptoms  whatever,  and  is  then  completely  beyond  the  grasp  of 
a  correct  diagnosis.  The  most  important  general  s3'mptoms  of  gangrene 
arise  from  the  introduction  into  the  general  circulation  from  the  gan- 
gi-enous  part  of  soluble  toxic  substances.  As  this  subject  will  be  treated 
of  more  exteusivel}'  in  the  chapter  on  Septicaemia,  it  will  suffice  here  to 
make  the  broad  but  correct  statement  that  septicaemia  complicates  gan- 
grene only  when  the  dead  tissues  are  infected  with  pus-microbes  or 
putrefactive  bacteria.  Dry  gangrene  is,  therefore,  not  attended  by  an}'' 
danger  of  septic  intoxication,  while  patients  suffering  from  moist  gan- 
grene with  putrefaction  die,  as  a  rule,  not  from  the  loss  of  tissue  from 
gangrene,  but  from  sepsis  incident  to  the  gangrene.  Sepsis  in  gangrene 
is  usually  of  that  variety  which  arises  from  the  introduction  into  the 
circulation  of  preformed  toxines,  the  symptoms  subsiding  with  the 
removal  of  the  cause,  with  the  exception  of  those  cases  of  progressive 
sepsis  caused  by  infection  with  pus-microbes. 


CHAPTER  VII. 

Necrosis  {continued). 

PATHOLOGICAL    AND   CLINICAL   VARIETIES   OF   NECROSIS. 

The  pathological  and  clinical  classification  of  necrosis  is  based  upon 
its  causes,  location,  extent,  and  the  age  of  the  patient.  The  causes  of 
necrosis  have  alread}^  been  considered,  and  it  has  been  shown  that  it 
results  either  from  arrest  of  the  circulation  from  purelj^  mechanical 
causes  or  from  the  action  upon  the  tissues  of  toxic,  chemical,  or  thermal 
influences  which  destroy  the  protoplasm  of  the  cells  directly.  The 
location  of  the  necrosis  is  important  to  remember,  as  when  it  occurs  in 
organs  inaccessible  to  saprophytic  micro-organisms  putrefaction  never 
takes  place;  on  the  other  hand,  necrosis  in  parts  accessible  to  atmos- 
pheric air  is  prone  to  be  followed  b}-  putrefaction,  with  all  the  dangers 
which  attach  themselves  to  this  condition.  The  extent  of  the  gangrene 
has  an  important  bearing  on  the  prognosis,  as,  when  the  causes  are  such 
as  to  determine  a  circumscribed  form  of  the  disease,  life  is  not  in  danger, 
while  the  progressive  form,  with  few  exceptions,  ends  in  death,  in  spite 
even  of  the  most  heroic  treatment.  The  age  of  the  patient  often  deter- 
mines the  form  of  gangrene,  as,  for  instance,  senile  gangrene  is  a  disease 
of  the  aged,  while  noma,  almost  without  exception,  attacks  only  children. 
The  simplest  and  an  exceedingly  common  form  of  necrosis  is  what  has 
been  described  Iw  Weigert  as 

Coagulation  Necrosis. — This  is  essentially  a  cell  necrosis.  It  is 
called  coagulation  necrosis  because  the  tissues  present  the  appearance 
of  coagulated  albumen,  and  also  on  account  of  the  process  resembling 
coagulation  of  the  blood.  Coagulation  necrosis  is  probablj'  identical 
with,  or,  at  any  rate,  nearl}'  allied  to,  the  hj'aline  degeneration  of  Reck- 
linghausen and  fibrinous  degeneration  of  E.  Wagner.  The  chemical 
process  which  results  in  coagulation  necrosis  is  as  yet  imperfectly  under- 
stood. Weigert  maintains  that  the  cell-protoplasm  and,  perhaps,  all 
albumen-containing  substances  are  converted  b}'  it  into  a  substance  re- 
sembling fibrin.  Macroscopicallj',  tissues  which  haA'e  undergone  this 
form  of  necrosis  present  a  yellowish  or  whitish  appearance,  and  are  of 
variable  consistence.  Under  the  microscope  the  cells  either  appear  un- 
changed in  form  or  their  place  is  occupied  bj'  thread-like  fragments  and 

(175) 


17()  PRINCIPLES   OF    SURGERY. 

gruuuliir  material.  Weigert  lays  down  as  the  earliest  change  witnessed 
in  a  cell  undergoing  coagulation  necrosis  disappearance  of  the  nucleus, 
wliich  is  the  case  twelve  to  twentj'-four  hours  after  the  process  com- 
menced. Fibrin  is  a  product  of  coagulation  necrosis  of  the  hlood. 
According  to  Alexander  Schmidt,  during  the  coagulation  of  blood  the 
colorless  corpuscles  disappear  ;  the  product  of  their  destruction  is  fibrin 
ferment  and  fibrino-plastic  material,  which,  Avith  the  fibrinogen  of  the 
plasma,  form  fibrin.  Isolated  cells  destroyed  by  coagulation  necrosis 
exfoliate,  and  are  transformed  into  a  homogeneous  granular  substance, 
which,  according  to  circumstances,  is  removed  by  absorption,  or  becomes 
encapsulated.  Cell  necrosis  en  masse  is  often  followed  by  calcification, 
and  on  surfaces  b3'  ulceration.  The  transformation  of  a  tubercular 
product  into  a  cheesy  mass  is  the  result  of  coagulation  necrosis.  As 
essential  conditions  for  coagulation  necrosis  to  occur  Weigert  enumer- 
ates:  1.  Death  of  tissue-cells.  2.  Presence  of  plasma-fluids.  3.  Tissues 
must  contain  coagulable  substances.  Coagulation  necrosis  is  retarded 
b}'  the  ptomaines  of  pus-microbes,  putrefying  material,  and  living  epi- 
thelial cells.  An  entire  organ  ma^'  be  destroyed  by  coagulation  necrosis. 
Pale  infarcts  after  embolism  are  products  of  this  change.  The  so-called 
fibrin  wedges,  which  were  formerly  regarded  as  a  decolorized  blood-clot, 
consist  of  such  tissues.  At  first  the  cells  are  normal  in  outline  and 
appearance ;  later,  the  nuclei  disappear  and  the  cells  break  up  into 
granular  masses.  In  the  internal  organs  coagulation  necrosis  is  most 
frequently  met  with  in  the  kidneys,  spleen,  typhoid  deposits,  tubercular 
lesions,  the  vicinity  of  mycotic  foci,  and  in  atheroma  of  the  blood- 
vessels. In  the  parenchyma  of  organs  it  attacks  the  epithelial  cells, 
while  the  connective  tissue  remains  intact.  On  raucous  surfaces  it  is 
represented  b}"^  the  diphtheritic  and  croupous  exudations.  While  the 
chemical  jyrocesses  which  take  place  in  coagulation  necrosis  cannot  as 
yet  be  explained  satisfactorily,  there  can  be  no  doubt  that  this  form  of 
necrosis  is  nearly  always,  if  not  always,  of  mycotic  origin,  and  it  must  be 
regarded  practically  in  the  light  of  a  bacterial  necrosis.  Klebs  describes 
the  same  condition  askarijolysis,  karyorhexis,  !xnd  vacuolar  degeneration. 
He  claims  that  early  disappearance  of  the  nucleus  is  not  an  essential,  but 
an  accidental,  condition.  In  a  case  of  pseudo-diphtheria  Klebs  found  the 
l)acilli  between  cells  devoid  of  nuclei,  and  onl}-  in  the  centre  of  the 
necrotic  patch  did  he  find  bacilli  within  the  cells  ;  from  this  he  concluded 
that  karyolysis  is  due  to  the  action  of  chemical  products  of  the  bacilli. 
In  the  second  group  of  mycotic  necroses  the  process  differs  as  in  typhus. 
Here  the  necrotic  centre,  which  contains  no  cells,  is  surrounded  by  a  zone, 
in  which  both  cells  and  nuclei  are  also  absent,  but  which  contains  a  large 
number  of  chromatin  bodies,  Ijdng  free  in  the  tissues.     As  these  bodies 


PATHOLOGICAL    AND    CLINICAL   VARIETIES   OF   NECROSIS.       HT 

are  found  in  a  location  where  the  cells  and  nuclei  have  been  destroj'ed, 
it  can  hardly  be  donbted  that  they  represent  remnants  of  these.  Accord- 
ing to  Wolmkom  and  Grassle,  these  bodies  are  liberated  by  rupture  of 
the  nuclear  envelope.  This  method  of  cell  destruction  is  called  karyo- 
rhexis.  A  third  form  of  cell  necrosis  is  vacuolar  degeneration^  in  "which 
the  change  is  initiated  in  the  protoplasm  itself.  This  must  not  be  mis- 
taken for  cell  oedema.  In  vacuolar  degeneration  the  protoplasm  ruptures, 
and  the  nuclei  of  epithelial  cells,  which  line  a  hollow  viscus,are  liberated, 
as  Langhans  observed  in  this  form  of  cell  necrosis  in  the  kidne3\  The 
cell  ruptures  on  account  of  increased  intra-cellular  pressure,  and  the 
process  well  deserves  the  name  plasma  rhexis.  This  form  of  cell 
destruction  was  formerly  considered  a  post-mortem  change.  For  the 
sake  of  simplicity  it  is  advisable  to  substitute  for  the  different  forms  of 
cell  necrosis  described  b}^  Klebs  the  general  term,  coagulation  necrosis, 
devised  b}'  Weigert. 

Necrobiosis. — This  is  a  term  applied  b}'  Yirchowto  the  spontaneous 
wearing  out  of  living  parts.  Death  of  isolated  cells  is  a  ph^'siological 
process  as  long  as  the}'  are  replaced  by  new  cells  of  the  same  tissue  type. 
Necrobiosis  occurring  on  a  more  extensive  scale  is  a  pathological  con- 
dition, and  is  etiologically  identical  with  coagulation  necrosis.  The  term 
can  be  used  to  signify  circumscribed  cell  necrosis  without  reference  to 
its  etiology  or  minute  morbid  anatomy. 

Progressive  Gangrene. — This  form  of  gangrene  is  alwa3^s  of  bacterial 
origin.  The  microbe  most  frequently  found  in  the  tissues  is  the  strep- 
tococcus p3'ogenes.  It  occurs  most  frequently  after  w^ounds  which  open 
up  a  large  surface  of  loose  connective  tissue,  as  in  compound  fractures, 
compound  dislocations,  excision  of  the  breast,  with  removal  of  axillary 
glands  and  extirpation  of  large,  fatty  tumors.  The  streptococcus  in- 
vades the  connective-tissue  spaces  rapidly,  somewhat  after  the  manner 
of  diffusion  of  the  streptococcus  through  the  lymphatic  vessels.  Much 
of  the  connective-tissue  necrosis  results  from  the  direct  action  of  the 
pus-microbes  and  its  ptomaines  on  the  cells.  The  necrosis  of  the  skin 
is  no  indication  of  the  extent  of  the  disease  in  the  deeper  tissues.  The 
infection  is  initiated  by  a  chill,  and  the  fever  which  follow  resembles  severe 
sepsis  from  other  causes.  If  infection  occur  during  the  operation,  or 
at  the  time  of  accident,  the  first  symptoms  may  be  looked  for  within 
fortj^-eight  to  sevent3'-two  hours.  If  suppuration  has  occurred  it  is 
diminished  with  the  appearnnce  of  septic  infection,  and  the  discharge 
becomes  thinner  and  sanious.  Lymphangitis  fi-equentl}^  accompanies 
the  deep-seated  phlegmonous  inflammation.  Gangrene  appears  in  the 
tissues  first  affected,  and  spreads  rapidl^'^  along  the  connective  tissue. 
Not  only  the  gangrene  is  progressive,  but  also  the  attending  septicaemia. 


178  PRINCIPLES   OF   SURGERY* 

The  larger  the  area  of  necrosis,  the  more  extensive  the  field  for  the  gf  owth 
of  pus-microbes  and  putrefactive  bacteria.  Pi'ogressive  gangrene  is  an 
exceeding!}^  dangerous  form  of  infection,  and  unless  treated  by  heroic 
measures  at  an  early  stage  is  sure  to  lead  to  a  speedy  fatal  termination. 

Progressive  Gangrene,  with  Emphysema. — Etiologically  this  form  of 
gangrene  is  identical  with  the  preceding  plus  secondary  infection  with 
gasogenic  bacteria.  The  necrosed  tissue  answers  the  purpose  of  a 
nutrient  medium  for  saprophytic  micro-organisms,  which  not  only 
generate  gas  which  is  diffused  through  the  dead  tissues,  but  the  soluble 
toxic  substances  which  they  elaborate  in  the  necrotic  area  are  absorbed 
into  the  circulation, — an  occurrence  which  gives  rise  to  toxaemia.  Em- 
physema almost  always  extends  far  beyond  the  limits  of  the  visible 
gangrene,  but  its  presence  is  a  sure  indication  of  the  extent  of  the  in- 
fection in  the  deep-seated  tissues.  Progressive  gangrene,  with  emphy- 
sema, is  the  most  fatal  form  of  gangrene,  and  only  in  exceptional  cases 
will  the  surgeon  succeed  in  warding  off  a  certain  fatal  termination  b}- 
early  operative  interference.  In  both  kinds  of  progressive  gangrene  the 
part  is  swollen,  cedematous,  the  skin  presenting  first  a  livid,  bluish  color, 
which  afterward  shades  into  a  greenish  or  reddish-black  hue.  Bullae, 
containing  a  reddish  serum,  form  at  points  where  the  gangrene  is  spread- 
ing. Besides  sulphuretted  hj^drogen,  butyric  and  valerianic  acid,  am- 
monia sulphur,  etc.,  are  some  of  the  many  chemical  products  of  putre- 
faction. The  rapidity  with  which  progressive  gangrene,  with  and  without 
emphysema,  spreads,  has  led  the  French  authors  to  apply  to  them  the 
term  gangrene  foudroyante. 

Moist  Gangrene. — Progressive  gangrene  is  necessarily  a  moist  gan- 
grene, as  bacteria  cannot  germinate  without  moisture.  All  forms  of 
mycotic  gangrene  are  forms  of  moist  gangrene.  All  necrosis  in  the 
interior  of  the  body  belong  to  this  variety.  The  moisture  of  the  dead 
tissue  is  due  to  imbibition  of  the  a?dema-fluid,  and  consequently  moist 
gangrene  is  apt  to  follow  vascular  conditions,  in  which  there  is  some  im- 
pediment to  the  return  of  venous  blood,  as  in  cases  of  obstruction  in  a 
large  arter^^,  and  more  especially  when  a  large  vein  has  become  obliterated 
by  a  thrombus.  Moist  gangrene  is  attended  by  all  the  dangers  incident 
to  putrefaction.  In  this  form  of  gangrene  the  line  of  demarcation  is  the 
seat  of  suppurative  inflammation. 

Dry  Gangrene. — In  dry  gangrene  the  dead  tissue  undergoes  mum- 
mification, and  on  this  account  the  soil  is  unfitted  for  the  germination 
of  putrefactive  bacteria.  Dry  gangrene  is  usually  the  result  of  a  trauma, 
the  action  of  a  chemical  substance,  or  it  follows  a  diminished  blood- 
supply.  In  senile  gangrene  it  follows  in  consequence  of  a  gradual 
diminution  of  blood-supply,  owing  to  atheromatous  degeneration  of  the 


PATHOLOGICAL    AND    CLINICAL   VARIETIES   OF    NECROSIS.       17!) 

arteries,  while  tlie  return  of  venous  blood  remains  unimpaired.  Dry 
gangrene  is  often  an  aseptic  gangrene.  If  no  infection  take  place  with 
pus-microbes  the  line  of  demarcation  is  formed  by  granulation  tissue, 
and  the  gangrenous  part,  if  small,  is  absorbed,  or  if  this  is  impossible  on 
account  of  its  size  it  is  separated  b}'^  the  granulations.  If  suppuration 
take  place  this  occurs  at  the  junction  of  the  dead  with  the  living  tissues. 
Dry  gangrene  is  usually  not  attended  by  any  general  s3'mptoms,  and  all 
attempts  to  remove  the  dead  tissue  should  be  postponed  until  the  line 
of  demarcation  has  formed. 

Senile  Gangrene. — This  is  the  gangrene  of  the  aged,  or,  rather,  it  is 
the  gangrene  which  is  caused  by  atheromatous  degeneration  of  the 
arteries.  Senile  marasmus,  in  the  form  of  atheromatous  degeneration 
of  the  arteries,  may  occur  in  persons  less  than  40  years  of  age,  and  is 
often  absent  in  octogenarians.  Senile  gangrene  alwaj's  occurs  in  parts 
where  the  circulation  is  feeblest ;  consequentlj'  it  usually  commences  in 
one  of  the  toes.  If  the  necrosed  tissue  remain  aseptic  the  rapidit}'  of 
the  extension  of  the  gangrene  depends  on  the  condition  of  the  blood- 
vessels. It  may  remain  limited  to  one  toe,  or  it  maj^  extend  from  toe  to 
toe,  and  then  creep  along  the  dorsum  or  plantar  surface  of  the  foot,  or 
on  both  sides  simultaneous!}',  and  extend  quite  rapidly  to  the  leg  as  far 
as  the  knee.  Usually  the  disease  extends  along  the  course  of  one  of  the 
principal  arteries,  and  extends  later  to  other  parts  of  the  foot  in  con- 
sequence of  greater  embarrassment  of  the  arterial  and  venous  circula- 
tion. If  infection  in  the  vicinity  of  the  necrosed  tissue  with  pus- 
microbes  take  place,  a  suppurative  inflammation  maj^  follow  senile  gan- 
grene, which  will  give  rise  to  a  progressive  and  rapidly-fatal  form  of  the 
disease.  In  the  dr}'  form  of  senile  gangrene  the  tissues  mummify,  are 
firm,  and  perfecth'  black  in  color.  In  the  moist  variety  the  parts  present 
the  same  appearances  as  in  progressive  gangrene.  If  a  line  of  demarca- 
tion form,  the  separation  of  the  dead  from  the  living  tissues  requires 
an  unusualh'  long  time,  as  the  circulation  is  enfeebled  to  such  an  extent 
that  tissue  proliferation  takes  place  very  slowly. 

Diabetic  Gangrene. — It  is  a  well-known  clinical  fact  that  persons 
suffering  from  diabetes  are  verj^  prone  to  be  attacked  by  gangrene.  The 
reasons  for  this  are  as  yet  unknown.  Gangrene  occurring  from  trivial 
causes  in  persons  presenting  the  appearances  of  usual  health,  and  in 
whom  no  evidences  of  atheromatous  degeneration  of  the  arteries  can  be 
detected,  should  awaken  the  suspicion  of  the  existence  of  diabetes,  and 
no  time  should  be  lost  in  making  a  careful  examination  of  the  urine.  A 
strictl}'  antidiabetic  diet  has  often  resulted  in  arresting  further  extension 
of  the  gangrene.  Kdnig  has  found  that  after  amputation  for  gangrene  in 
diabetics  the  quantit}^  of  sugar  in  the  urine  is  diminished. 


180  rRTNCIPLES   OF    SURGERY. 

Decubitus. — Gangraena  per  decubitumliteraWy  means  gangrene  from 
pressure.  It  occurs  in  consequence  of  pressure  from  splints,  bandages, 
and  the  prolonged  recuml)ent  position  in  bed,  especially  in  persons 
suffering  from  fracture  of  the  spine,  or  acute  infectious  diseases  attended 
by  great  impairment  of  the  circulation.  Pressure  without  infection  is 
productive  of  dry  aseptic  gangrene,  but  usually  gangrene  from  this 
source  is  complicated  by  infection  with  p3'ogenic  or  putrefactive  bacteria, 
or  both.  If  gangrene  from  pressure  is  inevitable,  it  is  apparent  that  its 
occurrence  should  be  met  b}-^  timely  precautions  for  the  purpose  of  pre- 
venting accidental  infection.  Gangrene  from  splint  pressure  can  be 
prevented  by  interposing  between  the  splint  and  bony  prominences  a 
thick  cushion  of  salic3dized  cotton.  Bed-sores  should  be  prevented  by 
changing  the  position  of  patient  frequently  and  protecting  the  parts 
most  exposed  to  the  ill  effects  of  pressure  with  fenestrated  rubber 
cushions,  by  enforcing  absolute  cleanliness,  and  b}^  keeping  the  skin 
in  a  healthy  condition  by  applications  of  spirituous  lotions.  Both  in 
gangrsena  per  decubitum  and  senile  gangrene  the  necrosis  is  caused  by 
impairment  or  complete  suspension  of  the  capillary  circulation. 

Noma. — Noma,  cancer  aquaticus,  is  characterized  by  rapid,  gan- 
grenous destruction  of  the  cheek,  which  usuallj-  commences  some  distance 
from  the  lips.  This  disease  is  exceedingly  rare  in  this  country,  but  quite 
prevalent  in  the  large  cities  of  Europe.  It  attacks  exclusively  children, 
occurring  most  frequently  between  the  ages  of  3  and  8  years.  Healthy 
children  seldom  suffer  from  this  disease ;  it  either  appears  in  badly- 
nourished,  cachectic  subjects,  or  it  occurs  as  a  complication  of  some  of 
the  eruptive  fevers  or  typhus.  In  reference  to  the  etiology  of  noma, 
little  is  known.  The  almost  constant  occurrence  of  the  disease  in  a  dis- 
tinct part  of  the  cheek  and  its  limitation  to  one  side  of  the  face  would 
indicate  that  it  might  be  the  result  of  some  nervous  disturbance.  It  is, 
however,  more  probable  that  it  is  a  form  of  m3^cotic  necrosis.  A  few 
observations  on  the  bacterial  origin  of  noma  have  been  made.  Lingard 
found  in  the  tissues  a  long  bacillus,  which  he  believed  was  the  cause  of 
the  disease.  In  gangrenous  stomatitis  in  the  calf,  which  affects  this 
animal  at  particular  seasons  of  the  year,  he  found  bacilli  which  are  very 
similar  in  appearance  to  those  present  in  noma  in  man.  On  cultivation 
they  present  characters  which  render  them  easily  distinguishable  from 
other  bacteria,  and  on  inoculation  of  these  micro-organisms  into  the  calf 
a  gangrenous  stomatitis  is  again  produced. 

Ranke's  investigations  on  noma  led  to  the  following  conclusions: 
Different  forms  of  gangrene  resulting  from  noma  can  unquestionably 
occur  spontaneously  in  children  who  have  a  tendencj'  to  disease  of  this 
character;  that  is,  without  infection  from  contact.     The  frequent  occur- 


PATHOLOGICAL    AND    CLINICAL   VARIETIES    OF    NECROSIS.       181 

rence  of  noma  in  public  institutions,  and  the  apparent  preference  of  the 
disease  for  localization  upon  the  mucous  membrane  of  the  different 
openings  of  the  body,  suggest  that  the  origin  of  it  may  be  referred  to 
the  invasion  from  without  of  micro-organisms.  In  the  zone  of  tissue 
contiguous  to  that  which  has  iindergone  necrosis  ma}^  be  found  cocci, 
which  in  number  appear  like  a  pure  culture.  At  the  periphery  of  the 
necrotic  zone  which  has  been  invaded  by  cocci  the  connective  tissue  is 
found,  in  a  state  of  active  proliferation.  The  entire  condition  is  suggest- 
ive of  the  tissue  necrosis  in  field-mice,  which  is  caused  b\'  a  chain  coccus, 
described  b}'  Koch.  Up  to  the  present  time  the  specific  nature  of  the 
cocci  wiiieh  Ranke  found  in  noma  tissues  has  not  been  shown.  Undoubt- 
edl}',  further  bacteriological  research  will  prove  that  noma  is  a  mj'cotic 
necrosis,  an<l  that  the  dead  tissue,  like  in  other  forms  of  necrosis,  is 
subsequently  invaded  with  putrefactive  bacilli.  The  disease  commences 
as  a  circumscribed  livid  spot  upon  the  surface  of  the  mucous  membrane 
of  the  mouth,  and  a  corresponding  portion  of  the  clieek  in  its  entirety 
is  indurated.  Soon  the  color  of  the  aflfected  mucous  membrane  becomes 
darker,  and  the  skin,  which  at  first  presented  a  dusky  appearance,  is 
turned  nearly  black,  and  the  epidermis  is  elevated  in  a  blister,  which 
afterward  is  turned  into  a  black  eschar.  With  the  separation  of  the 
gangrenous  part  an  opening  in  the  cheek  is  left  without  an}^  sign  of  a 
line  of  demarcation.  The  gangrene  spreads  in  all  directions,  and,  if  not 
arrested  spontaneously  or  by  the  use  of  energetic  measures,  often 
destro3s  the  entire  cheek.  Tlie  disease  is  not  limited  to  the  soft  tissues, 
but  attacks  the  maxillary  bones,  often  causing  extensive  necrosis  and 
loss  of  teeth.  The  gangrene  seldom  extends  beyond  the  median  line  in 
the  lips,  and  the  tongue  usually  remains  free.  In  the  majority  of  cases 
the  disease  is  fatal.  Death  is  pi-eceded  by  symptoms  of  intense  sepsis, 
with  secondary  septic  inflammation  of  some  of  the  internal  organs, 
especially  the  intestines  and  lungs.  In  some  cases  a  gangrenous  affec- 
tion of  the  genital  organs  occurs,  which  in  every  respect  resembles  the 
affection  of  the  cheek.  In  case  recovery  takes  place,  the  defect  caused 
by  the  necrosis  has  to  be  restored  by  a  plastic  operation. 

Hospital  Gangrene. —  Gangrsena  nosocomialis,  ulcer ative-wound  diph- 
theritis,  only  occurs  as  an  infection  of  wounds,  and,  as  the  name  hospital 
gangrene  indicates,  is  seldom  met  with  outside  of  large  unsanitary  hos- 
pitals. Before  wounds  were  treated  antisepticall}',  it  occurred  as  a  fre- 
quent complication  after  operations  or  open  injuries  in  most  of  the  Euro- 
pean hospitals.  It  was  prevalent  among  the  wounded  during  the  War  of 
the  Rebellion.  Thanks  to  the  labors  of  Lister  and  his  followers,  it  has  now 
disapi)eared  almost  completely  among  civilized  nations.  The  simple  fact, 
that  this  dreadful  disease  has  been  almost  completely  expunged  from  the 


182  nnxciPLES  of  suiigerv. 

oldest  aiul  most  infected  hospitals  b}-  the  antiseptic  treatment  of  wounds 
furnishes  conclusive  proof  of  its  mj'cotic  origin.  Unfortunately,  prac- 
tical bacteriology  was  born  too  late  to  take  advantage  of  the  numerous 
opportunities  to  stud}^  the  etiology  of  this  form  of  wound  infection.  A 
feature  of  this  disease  of  unusual  bacteriological  interest  is  the  fact 
that  it  attacks  not  only  recent  wounds,  but  also  wounds  covered  by 
healthy  granulations.  A  health3^  granulating  surface  is  considered  as 
a  good,  if  not  an  absolute,  protection  against  the  ordinary  pathogenic 
bacteria  which  infect  wounds,  but  the  microbe  of  hospital  gangrene 
manifests  no  sucli  discretion.  The  first  evidence  of  the  appearance  of 
hospital  gangrene  is  the  f(jru)ation  of  a  3'ellowish,  pultaceous  mass  upon 
the  surface  of  a  recent  wound  or  upon  a  granulating  surface.  This  mass 
can  be  readily  wiped  away,  with  the  exception  of  the  lowest  laj-ers, 
which  are  firmly  attached  to  the  surface.  The  skin  in  the  immediate 
vicinit}'  of  this  deposit  becomes  red  and  inflamed,  and  is  soon  displaced 
by  the  same  material.  The  original  wound  assumes  a  3'ellowish-gray 
appearance,  and  is  rapidly  enlarged  by  the  extension  of  the  destructive 
process.  Within  three  da^'s  to  a  week  the  wound  is  enlarged  to  double  its 
original  size.  In  this  the  pulpous  form  of  the  disease,  extension  toward 
the  depth  of  the  wound  is  slow,  as  fascia  and  muscles  offer  considerable 
resistance  to  its  progress  in  this  direction.  In  the  ulcerative  form  of 
hospital  gangrene  the  wound  or  granulation  surface  becomes  the  seat  of 
an  ichorous  discharge,  and  the  tissues  undergo  rapid  destruction  by 
molecular  disintegration.  The  ulcerative  form  of  hospital  gangrene 
makes  more  rapid  progress  than  the  pulpous.  Although  these  two  forms 
occur  as  distinct  affections  throughout,  combinations  of  the  two  have 
been  observed.  Hospital  gangrene,  in  preference,  attacks  small  wounds, 
as  punctures,  the  bites  of  leeches,  abrasions,  blistered  surfaces,  etc. 
Many  authors  have  been  inclined  to  believe  that  diphtheritic  inflamma- 
tion of  a  wound  and  hospital  gangrene  are  identical,  but  so  far  no 
positive  proof  of  such  identit}'  has  been  furnished.  The  clinical  course 
of  both  of  these  processes  is  nearly  the  same,  but  etiologically  and 
pathologicall}'^  tlie  differences  are  apparent.  Heine  claimed  that  he 
observed  hospital  gangrene  where  the  wounds  were  infected  with  virus 
from  patients  suffering  from  genuine  diphtheria,  and  again  he  saw  genu- 
ine diphtheritic  lesions  of  mucous  membranes  in  patients  who  were 
exposed  to  the  contagium  of  hospital  gangrene.  The  general  sj^mptoms 
in  the  ])eginning  of  an  attack  of  hospital  gangrene  are  not  severe.  The 
patient  complains  of  a  loss  of  appetite  and  a  general  feeling  of  malaise. 
In  old  persons,  children,  and  debilitated  subjects,  it  may  prove  fatal  with- 
out the  occurrence  of  special  complications.  One  of  the  great  dangers 
which  attend  hospital  gangrene,  especially  the  ulcerative  form,  is  second- 


PATHOLOGICAL    AND    CLINICAL    VARIETIES    OF    NECROSIS.       l'>3 

ary  haemorrhage.  During  the  pulpy  degeneration  or  molecular  disinte- 
gration of  the  tissues  vessels  are  implicated,  and  a  sudden  haemorrliao-e 
from  a  large  vessel  frequently  leads  to  a  rapidly  fatal  termination.  The 
large  vessels  show  an  unusual  resistance  to  the  destructive  effect  of 
hospital  gangrene,  but  not  infrequently  the}'  give  way,  especially  if  the 
disease  attack  a  stump  after  amputation.  Septic  intoxication  is  never 
so  well  marked  in  hospital  gangrene  as  in  diphtheritic  affections  of 
mucQUS  membranes.  Billroth  believes  that  hospital  gangrene  is  caused 
by  a  specific  micro-organism  which  is  onl}-  reproduced  under  certain 
atmospheric  conditions;  hence  tlie  appearance  of  the  disease  formerly  in 
an  epidemic  form.  Clinical  observations  leave  no  doubt  that  tlie  disease 
is  carried  from  one  patient  to  another  by  means  of  sponges,  instruments, 
hands,  etc. 

Perforating  Ulcer  of  Stomach  and  Duodenum. — These  ulcers  follow 
circumscribed  necrosis  of  the  wall  of  the  stomach  or  duodenum,  caused 
by  a  diminished  arterial  blood-supply  of  a  limited  vascular  district. 
Tliat  these  ulcers  are  of  vascular  origin  is  shown  by  their  shape  and 
direct  relation  to  an  arter3\  The  defect  is  in  the  form  of  a  cone,  the 
base  being  directed  toward  the  lumen  of  the  viscus,  and  the  apex  cor- 
responds witli  a  small  arter\'  which  must  have  been  partially  or  com- 
pletely obstructed  before  the  necrosis  occurred.  These  ulcers  are 
sometimes  multiple,  and  in  the  stomach  they  are  found  in  preference 
along  the  lesser  curvature.  After  interruption  of  the  arterial  circula- 
tion the  wedge-shaped  ischeemic,  necrosed  portion  is  removed  by  the 
action  of  the  gastric  juice,  and  the  ulcer  is  made.  As  perforating  ulcer 
of  the  stomach  or  duodenum  never  occurs  in  cases  of  ulcerative  endocar- 
ditis, but  selects  in  preference  3'oung  females,  the  causes  of  vascular 
obstruction  must  be  of  a  local  nature.  The  sphacelus  shows  molecular 
decay,  but  no  trace  of  inflammation.  Perforating  ulcers  of  the  stomach 
and  intestines  are  of  interest  to  the  surgeon,  because  in  case  of  perfora- 
tion their  treatment  has  been  brought  within  the  legitimate  sphere  of 
abdominal  surgery.  The  more  frequent  occurrence  of  perforation  is 
prevented  by  circumscribed  plastic  peritonitis,  which  seals  the  defect  or 
establishes  an  adhesion  between  the  affected  portion  of  the  organ  and 
some  other  organ. 

Perforating  Ulcer  of  Foot. — This  ulcer  follows  a  localized  necrosis 
of  the  foot,  wliich  is  supposed  to  be  in  part,  at  least,  the  consequence  of 
vasomotor  disturbances,  to  whicli  are  added  impediments  to  the  circula- 
tion and  frequently  infection  with  pathogenic  micro-organisms.  This 
ulcer  is  remarkable  for  the  regularity  of  its  outline,  looking  as  though  a 
piece  had  been  cut  out  with  a  punch.  The  defect  corresponds  to  the 
shape  of  the  detached  necrosed  tissue.     The  necrosis  affects  all  of  the 


1S4  PRINCIPLES    OF    SURGERY. 

tissues  of  the  part  in  which  it  occui's,  not  even  sparing  the  bones  and 
articuhitions  of  the  foot.  The  dissections  of  Duphxy,  Morat,  Fischer, 
and  others  leave  no  doubt  that  this  strange  ulcer  originates  from  necro- 
sis following  degeneration  of  the  nerves  of  the  affected  region.  Infec- 
tion with  pus-microbes  follows  the  necrosis, — an  occurrence  which  renders 
the  treatment  more  intractable. 

Ergotine. — One  of  the  effects  of  chronic  ergot  intoxication  is 
symmetrical  dry  gangrene.  Bread  made  of  flour  containing  ergot  has 
not  infrequently  occasioned,  in  Euroi)e,  fatal  epidemics,  usually  attended 
with  dry  gangrene.  As  before  stated,  the  gangrene  following  the  i.>ro- 
lonjred  administration  of  this  drug  is  either  the  result  of  a  chronic 
angiospasm,  or  of  a  paralytic  effect  of  the  drug  on  the  peripheral 
nerves. 

Prognosis. — ^The  prognosis  in  a  case  of  gangrene  should  be  based 
on  the  etiolog}^  location,  and  extent  of  the  disease  which  caused  the  gan- 
grene. The  existence  of  complications  must  also  be  taken  into  careful 
consideration.  Acute,  rapid ly-s[)reading  gangrene,  irrespective  of  the 
causes  which  may  produce  it,  must  always  be  considered  as  an  exceed- 
ingly grave  condition.  Mycotic  progressive  gangrene,  with  and  without 
emphysema,  unless  treated  early  and  heroically,  proves  fatal  almost  with- 
out exception,  death  resulting  from  septiciemia.  Gangrene  following 
obliteration  of  the  principal  artery  of  a  limb  would  result  in  death,  in 
the  majority  of  cases,  unless  a  fatal  sepsis  is  prevented  by  early  amputa- 
tion. Necrosis  of  the  entire  or  greater  part  of  important  internal 
organs  is  incompatible  with  life  from  the  greatly  diminished  or  com- 
pletely suspended  function  of  important  organs.  The  prognosis,  so  far 
as  life  is  concerned,  in  cases  of  senile  gangrene,  is  rendered  exceedingl}'^ 
grave  when  the  gangrene  spreads  rapidly,  in  consequence  of  an  ascending 
arterial  thrombosis,  or  thrombo-phlebitis,  and  life  is  in  imminent  danger 
when  the  gangrene  due  to  diminished  blood-suppl}'^  is  complicated  by  a 
rapidly-spreading  suppurative  inflammation,  or  if  septic  intoxicntion 
arise  from  invasion  of  the  moist  necrosed  tissue  with  putrefactive  bac- 
teria. The  general  condition  and  age  of  the  patient  play  an  important 
part  in  arriving  at  correct  prognostic  conclusions.  Patients  debilitated 
from  antecedent,  acute,  and  chronic  disease  are  in  greater  peril  of  life 
than  robust,  healthy  persons  whose  circulation  and  tissue  resistance  has 
not  been  impaired.  Infants  and  the  aged  succumb  to  gangrene  more 
readily  than  young  adults  and  persons  in  middle  life,  although  the  gan- 
grene may  have  resulted  from  the  same  causes,  reached  the  same  extent, 
and  inoculated  the  same  parts.  Gangrene  of  some  important  organ,  as 
the  lungs  or  intestines,  is  more  dangerous  to  life  than  peripheral  gan- 
grene.    The    co-existence    of  complications,  such  as  diabetes,  Bright's 


PATHOLOGICAL    AND    CLINICAL    VARIETIES   OF    NECROSIS.       185 

disease,  tul)erculosis,  valvular  disease  of  the  heart,  and  cirrhosis  of  the 
liver  will  iiilluence  the  prognosis  correspondingly. 

Treatment. — The  prophylactic  treatment  includes  such  measures, 
medicinal,  dietetic,  and  otherwise,  that  are  calculated  to  improve  the 
blood-supply  of  the  part  threatened  with  gangrene,  and  if  this  has 
occurred,  or  is  inevitable,  to  prevent  putrefaction  of  the  dead  tissues, 
in  threatened  gangrene  from  obstruction  of  the  main  artery  of  a  limb, 
the  estal)lisiiment  of  collateral  circulation  must  be  aided  by  placing  the 
limb  in  a  horizontal  or  slightly-elevated  position,  and  by  the  external 
application  of  dry  heat.  In  the  aged  suffering  from  premonitory  periph- 
eral symptoms  of  gangrene,  its  actual  occurrence  can  often  be  posti)oned 
by  massage,  rubbing  the  limb  from  the  toes  toward  the  body  for  ten  or 
fifteen  minutes  twice  daily,  and  by  the  avoidance  of  all  causes  which 
would  bring  about  stasis  in  the  enfeebled  blood-vessels.  The  minutest 
lesions  of  the  skin,  as  abrasions,  corns,  bimions,  ulcers,  etc.,  should 
receive  careful  attention  in  all  persons  the  subjects  of  a  feeble  circulation, 
as  they  frequently  are  the  starting-point  of  a  gangrenous  inflammation. 
Diabetic  persons  are  exceedingly  liable  to  be  attacked  with  gangrene 
after  the  slightest  operation  or  the  most  insignificant  injur}-,  and  on  this 
account  it  is  advisable  to  examine  the  urine  before  undertaking  an 
operation  in  persons  presenting  the  faintest  evidences  of  this  disease. 
As  most  forms  of  gangrene  are  of  mycotic  origin,  all  infective  atria 
should  be  protected  against  infection  from  without  by  thorough  antiseptic 
precautions.  The  prevention  of  decubitus  has  already  been  referred  to, 
and  here  will  be  only  mentioned  the  necessit}^  of  securing  for  the 
iiecrosed  tissues  an  aseptic  condition  by  rigid  cleanliness  and  antiseptic 
measures  in  cases  where  the  necrosis  has  occurred,  or  where  it  cannot  be 
prevented.  In  moist  gangrene  the  prevention  of  putrefaction  is  a  most 
diflScult  task.  Where  gangrene  of  this  tj-pe  has  occurred,  or  is  antici- 
pated, the  whole  surface  far  beyond  the  area  involved  or  threatened 
should  be  rendered  aseptic  in  the  same  manner  as  in  the  preparation  for 
an  operation,  and  the  parts  protected  as  far  as  possi])le  against  invasion 
with  putrefactive  bacteria  bj'  an  absorbent  antiseptic  dressing.  A  few 
layers  of  gauze  and  a  thick  compress  of  salicylized  cotton  answer  an 
excellent  purpose  in  meeting  this  indication.  If  gangrene  with  putre- 
faction has  occurred,  the  etiological  indications  for  local  treatment  are 
best  met  by  multiple  incisions  through  the  necrosed  tissues  and  under- 
mined skin  and  the  application  of  a  compress  wrung  out  of  a  1-per- 
cent, solution  of  acetate  of  aluminum.  If  the  fcBtor  is  intense,  Labar- 
raque's  solution  of  chlorinated  soda,  properlj'  diluted,  answers  an 
admirable  purpose.  In  gangrene  with  partial  separation  of  the  slough 
and  considerable  undermining,  permanent  irrigation  with  either  of  these 


186  PRINCIPLES   OF    SURGERY. 

preparations  answers  tlie  best  purpose.  All  patients  suffering  from 
iianffrene  are  debilitated  from  antecedent  or  concomitant  causes,  and 
consequently  are  badly  affected  b}'  any  form  of  the  so-called  antiphlo- 
gistic or  sedative  treatment.  Fever  is  always  the  result  of  the  entrance 
of  septic  material,  and  should  therefore  not  be  treated  by  antipja-etics, 
but  by  local  measures  directed  toward  the  primary  cause.  Quinine  in 
sedative  doses  does  more  harm  than  good.  Veratrum  viride,  tartar 
emetic,  and  the  innumerable  chemical  substances  which  have  recently 
been  so  miicli  lauded  as  anti-fever  remedies  should  never  be  prescribed 
in  the  treatment  of  fever  attending  necrosis.  The  patient's  strength 
must  be  supi)orted  from  the  beginning  b3'  a  liberal  diet  and  the  use  of 
stimulants.  If  the  heart's  action  is  feeble,  digitalis  can  be  given  with 
benefit.  Quinine  in  tonic  doses  is  indicated.  Anorexia  not  dependent 
on  high  fever  calls  for  some  one  or  a  combination  of  bitter  tonics.  The 
part  affected  must  be  placed  at  rest  and  in  a  position  most  favorable  for 
the  passage  of  the  blood  through  tlie  capillaries. 

The  question  of  removal  of  gangrenous  tissue  and  the  amputation 
of  a  gangrenous  limb  should  receive  thoughtful,  conscientious  consider- 
ation before  an  operation  is  undertaken.  The  favorable  results  which 
have  followed  the  operative  removal  of  a  gangrenous  part  after  the  line 
of  demarcation  had  formed,  and  the  great  mortality  of  operations  under- 
taken without  such  a  positive  indication,  have  led  many  good  surgeons 
to  advise  postponement  of  all  operative  procedure  until  nature  has  indi- 
cated the  site  of  operation.  This  conservative  rule,  however,  is  incom- 
patible with  the  teachings  of  modern  surgery.  We  know  that  death  in 
cases  of  rapidlj'-spreading  gangrene  is  caused  by  septic  intoxication.  We 
also  know  that  the  cause  of  the  septic  intoxication  inhabits  the  dead 
tissue,  and  we  are  also  aware  that  the  extension  of  the  immediate  cause 
of  gangrene  (vessel-obstruction),  ascending  thrombosis  in  the  arteries, 
and  ascending  thrombo-phlebitis  in  the  veins  proceed  from  the  gangre- 
nous part.  In  view  of  these  facts,  the  delay  of  operative  measures  in 
the  treatment  of  gangrene  until  the  line  of  demarcation  has  been  estab- 
lished would  be  to  wait  for  something  which,  in  the  most  urgent  cases, 
never  occurs.  In  the  absence  of  sjmptoms  indicating  danger  from 
septicaemia  it  is  not  only  advisable,  but  absolutely  necessary,  to  postpone 
the  operative  removal  of  the  gangrenous  part  until  nature  locates  the 
site  for  the  operation  by  the  formation  of  the  line  of  demarcation.  In 
aseptic  dry  gangrene  involving  parts  where  no  formal  operation  is  neces- 
sary- to  secure  a  favorable  healing,  later  spontaneous  elimination  should 
be  waited  for,  and  after  separation  of  the  necrosed  tissue  the  granulating 
surface  is  treated  in  the  usual  manner.  In  moist  gangrene  the  dead 
tissue  is  removed  as  soon  as  partial  separation  has  taken  place  bv  divid- 


PATHOLOGICAL    AND    CLINICAL    VARIETIES   OF    NECROSIS.       187 

ing  with  scissors  the  more  resistant  structures,  as  fascia  and  tendons, 
after  which  the  resulting  wound  is  treated  upon  antiseptic  principles. 
In  gangrene  of  the  extieraities  amputation  can  be  done  safel}',  and  with 
good  prospects  of  success,  as  soon  as  the  line  of  demarcation  has 
formed.  In  such  cases  it  is  necessary  to  remove  as  little  as  possible  of 
the  health}'  tissue  b}'  carrying  the  incisions  in  such  a  manner  as  to  leave 
flaps  composed  of  health}^  tissue  simply  long  enough  to  cover  the  bone. 
No  t^'pical  operation  should  be  adopted,  as  the  flaps  must  be  made  not 
in  conformity  with  an}'  text-book  rules,  but  the  condition  of  the  limb.  If 
the  patient  is  febrile,  and  the  character  of  the  fever  indicates  as  its 
origin  the  gangrenous  part,  delay,  to  sa}'  the  least,  is  attended  b}^  in- 
creased danger  of  extension  of  the  gangrene,  and  death  from  septicaemia. 
Such  cases  fare  best  at  the  hands  of  prudent  but  courageous  surgeons. 
Procrastination  in  such  eases  is  a  sign  of  timidity  or  ignorance.  What 
is  to  be  done  must  be  done  at  once.  The  patient  and  friends  must  be 
made  acquainted  with  the  dangers  incident  to  dela}',  and  the  only  pros- 
pect of  recovery  by  early  amputation.  Consultation  Avith  one  or  more 
of  the  neighboring  physicians  is  an  absolute  necessity  in  such  cases. 
Fortified  by  a  fair  understanding  with  the  patient  and  his  friends,  sup- 
ported by  the  advice  and  counsel  of  one  or  more  of  his  colleagues,  no 
surgeon  need  fear  to  follow  the  dictates  of  his  conscience,  even  in  the 
most  unpromising  cases.  The  distinguished  Hueter  related  several  cases 
where  early  amputation  saved  the  life  of  patients  who  were  in  stupor 
from  the  eflJects  of  septic  intoxication  to  such  an  extent  that  an  anaes- 
thetic was  unnecessary.  Early  amputation  should  be  urged  and  done 
in  all  cases  where  life  is  placed  in  jeopardy  from  absorption  of  septic 
material  from  the  gangrenous  part.  The  results  after  amputation  under 
such  circumstances  will  always  remain  uncertain,  because  in  many  in- 
stances fatal  general  infection  occurs  soon  after  the  development  of  the 
first  general  s3^mptoms,  and  the  local  infection  frequently  extends  to  the 
site  of  operation,  rendering  a  recurrence  of  gangrene  in  the  stump  a 
great  probabilit}-.  Amputation  should  be  done,  as  near  as  possible, 
through  healthy  tissue.  Much  good  judgment  is  necessary  to  determine 
this  location.  It  is  safe  to  maintain  that  the  more  acute  the  attack,  the 
more  distant  should  the  amputation  be  made  from  the  apparent  boundar}'- 
line  of  the  gangrene.  In  gangrene  from  obstruction  of  a  large  blood- 
vessel and  in  gangrene  attended  by  ascending  thrombo-phlebitis,  arterial 
thrombosis,  or  both  of  these  conditions,  the  line  of  amputation  should 
fall  through  a  point  where  the  vessels  are  patent,  otherwise  a  recurrence 
of  the  disease  is  almost  sure  to  take  place.  Before  the  amputation  is 
made  the  part  to  be  removed  should  be  enveloped  in  towels  wrung  out 
in  an  antiseptic  solution  for  the  purpose  of  preventing  contamination  of 


188  PRINCIPLES   OF    SURGERY. 

the  wound  with  septic  iiuileiiul  Troin  the  dead  tissue.  It  is  almost  need- 
less to  mention  that  Esmarch's  elastic  bandage  should  never  be  used,  as 
b^'  its  application  septic  material  might  be  forced  into  the  circulation. 
The  limb  should  be  rendered  as  nearly  as  possible  bloodless  by  holding 
it  for  a  few  minutes  in  a  perpendicular  position,  when  an  elastic  con- 
strictor is  applied  some  distance  above  the  point  selected  for  tiie  ampu- 
tation. In  septic  patients  the  parenchymatous  oozing  sometimes  is 
dilHcult  to  control,  but  is  managed  most  successfully  by  keeping  the 
limb  in  the  elevated  position,  and  by  making  surface-pressure  with  a 
large,  flat  sponge  or  gauze  compress  wrung  out  in  hot  water.  As  most 
of  these  patients  are  prostrated  from  the  effects  of  the  disease,  they  are 
liable  to  suffer  from  shock,  and  measures  should  be  resorted  to  to  prevent 
this  complication,  or,  at  least,  diminish  its  severity.  For  this  purpose  a 
subcutaneous  injection  of  yj^  to  ^1^  grain  of  atropia  with  ^  grain  of 
morphia  is  administered  hypodermatically  before  the  anaesthetic  is  dimin- 
ished. Two  ounces  of  whisky  or  the  same  amount  of  brandy  is  given 
at  the  same  time  per  oi-em,  or,  preferably,  jper  i-ectum.  Ether  is  preferable 
to  chloroform  in  these  cases  as  an  anaesthetic.  After  the  operation  the 
most  careful  after-treatment  is  required  to  meet  possible  emergencies. 
Shock  is  treated  b}^  alcoholic  stimulants,  camphorated  oil,  musk,  and 
coffee.  If  the  stomach  is  irritable,  brandy,  whisk}',  or  coffee  is  admin- 
istered by  the  rectum.  Camphorated  oil  or  musk  is  given  hypoder- 
maticall}^  every  half-hour  until  the  patient  reacts.  External  heat  is  use- 
ful in  relieving  congestions  of  internal  organs  and  in  stimulating  the 
action  of  the  heart.  Amputation  wounds  made  through  tissues  that  are 
not  positivel}^  known  to  be  aseptic  should  alwa^'s  be  drained  ;  this  is  the 
more  necessary  if  the  soft  tissues  are  oedematous.  Should  the  tissues  at 
the  seat  of  amputation  not  present  a  satisfactory  appearance,  it  is  advis- 
able to  go  up  higher,  more  especially  if  the  vessels  are  obstructed  by  a 
thrombus.  The  fate  of  the  patient  is  decided  within  a  few  days  after 
the  amputation.  Tiie  most  favorable  symptom  is  a  reduction  of  the 
temperature  to  normal  within  a  few  hours  after  the  o[)eration,  which  will 
be  the  case  if  the  fever  has  been  caused  by  a  septic  intoxication.  With 
the  removal  of  the  tissues  which  furnished  the  toxic  substances  and  the 
elimination  of  these  through  the  secretory  orgaiis  the  septic  symptoms 
subside,  and  if  the  patient  has  sufficient  strength  left  to  carry  him  over 
the  immediate  effects  of  the  operation  the  prospects  of  recovery  are 
good.  If  the  patient  is  the  subject  of  a  progressive  sepsis,  the  amputa- 
tion, in  all  probability,  will  prove  powerless  as  a  life-saving  measure,  as 
the  microbes  which  have  reached  the  circulation  reproduce  themselves 
with  great  rapidity,  and  death  from  this  cause  results  within  a  few  hours 
to  several  days.     Prompt  improvement  soon  after  the  operation,  with 


PATHOLOGICAL   AND   CLINICAL   VARIETIES   OF   NECROSI?.       1 S9 

recurrence  of  febrile  sj-mptoms  in  a  few  da^'s,  indicates  the  occurrence 
of  gangrene  in  the  stump.  Such  S3-raptoms  demand  a  change  of  dressing. 
If  gangrene  is  present,  all  sutures  are  removed,  a  tiiorough  local  disin- 
fection practiced,  after  which  the  stump  should  be  treated  b}^  constant 
irrigation.  Reamputation  at  this  time  would,  in  all  probabilitj^  prove 
fatal,  and  reliance  on  local  disinfection,  combined  with  the  use  of  stimu- 
lants and  tonics,  is  advised,  with  a  feeble  hope  that  these  measures  may 
become  the  means  of  limiting  the  extension  of  the  disease,  and  of  sup- 
porting the  heart's  action  until  the  line  of  demarcation  is  established, 
when  the  surgeon's  services  are  again  required  to  assist  nature's  efforts 
in  the  elimination  of  the  dead  tissues.  In  noma  and  hospital  gangrene, 
the  infected  tissues  are  removed  with  the  sharp  spoon,  and  after  thorough 
antiseptic  irrigation  the  actual  cautery  is  applied,  and  the  further  man- 
agement of  the  wound  is  the  same  as  in  case  of  infected  wounds  from 
other  causes.  Chlorinated  water  or  a  solution  of  bromine  are  excellent 
preparations  after  the  primary  disinfection  and  cauterization  in  the 
treatment  of  these  diseases. 


CHAPTER  VIII. 

Suppuration, 
bacteriological  causes  and  histogenesis  of  suppuration. 

Suppuration  is  the  most  frequent  termination  of  acute  inflammation. 
Inflammation  terminating  in  the  formation  of  pus  is  called  suppurative, 
both  on  account  of  its  etiology  and  the  nature  of  the  inflammatory 
product.  Suppuration  is  the  process  by  which  the  morphological 
elements  of  the  iuflaramatory  product,  the  leucocytes,  and  embryonal 
cells  are  converted  into  pus-corpuscles.  Suppurative  inflammation  is 
caused  b}'  the  action  upon  the  tissues  of  specific  micro-organisms,  the 
pus-microbes,  and  the  transformation  of  leucocytes  and  embr^'onal  cells 
into  pus-corpuscles  is  accomplished  by  the  same  cause.  The  brilliant 
results  which  have  been  obtained  b}'^  the  antiseptic  treatment  of  wounds 
made  it  exceedingl}^  probable  that  all  wound-infective  diseases  are  caused 
by  living  micro-organisms.  The  probability  was  increased  when  Koch, 
in  1879,  showed  the  direct  connection  existing  between  certain  traumatic 
infective  diseases  in  animals  and  the  never-absent  definite  micro-organ- 
isms. It  requires  no  longer  any  arguments  to  show,  at  this  time,  that 
all  inflammatoi'y  wound  complications,  among  them  suppuration,  are, 
without  exception,  caused  by  the  introduction  into  the  tissues  of  specific 
pathogenic  microbes.  Etiological!}',  most  of  the  purulent  processes 
constitute  more  of  a  unity  than  was  formerly  believed,  and  the  clinical 
varieties  are  mostly  determined  by  the  intensity  of  the  infection,  the 
manner  of  localization,  and  the  degree  of  resistance  possessed  b}'  the 
tissues.  The  most  conclusive  evidence  of  the  correctness  of  this  asser- 
tion is  furnished  by  the  fact  that  the  same  streptococcus  which  produces 
a  simple  abscess  is  likewise  the  most  frequent  cause  of  progressive  gan- 
grene, and  of  that  most  grave  form  of  suppuration — p^'aemia. 

I.    HISTORY    OF    MICROBIC    ORIGIN    OF    SUPPURATION. 

As  in  the  case  of  nearly  all  infective  diseases,  j^ears  before  the 
specific  pus-microbes  were  discovered,  living  organisms  were  found  and 
described  in  pus,  and  were  believed  to  be  the  essential  cause  of  suppura- 
tion. T\vent3^-five  j'ears  ago  Klebs  discovered,  in  the  tubuli  uriniferi 
in  cases  of  pyelo-nephritis  following  suppurative  cvstitis,  between  the 

(191) 


192  PRTNCrPLES    OF    SURGERY. 

pus-cells,  small,  round  cocci,  which  he  believed  produced  the  infection. 
In  1872  the  same  author  published  the  result  of  his  researches,  during  the 
Franco-Prussian  war,  on  septic-wound  diseases.  In  this  work  he  again 
referred  to  the  micro-organisms  which  he  had  previously  described,  and 
showed  that  they  existed  in  the  tissues  and  organs — the  seat  of  suppu- 
rative inflammation — before  pus  had  formed.  He  also  showed  how  these 
micro-organisms  enter  the  circulation  and  become  the  direct  cause  of 
pathological  conditions  in  distant  organs.  Even  at  that  time  he  placed 
great  stress  on  the  fact  that,  as  long  as  the  cocci  remained  only  in  the 
tissues  at  the  point  of  infection,  they  produce  only  local  inflammation  or 
necrosis,  but  as  soon  as  the}'  enter  the  circulation  fever  and  other  symp- 
toms of  general  septic  infection  follow. 

Ogston,  the  discoverer  of  pus-microbes,  published  the  results  of  his 
observations  and  researches  in  1881.  This  patient  investigator  examined 
the  pus  of  69  abscesses  for  micro-organisms,  and  found  in  17  of  them  a 
chain  coccus  (streptococcus),  in  31  cocci  which  arranged  themselves  in 
groups  which  resemble  a  bunch  of  grapes  (staph^'lococcus),  and  in  16 
both  of  these  forms  were  present.  In  cold  abscess  he  was  unable  to  find 
either  of  these  micro-organisms.  He  also  ascertained  that  these  two 
forms  of  microbes  differed  in  their  manner  of  diffusion  in  and  action  on 
the  tissues,  as  the  streptococcus,  following  the  lymph-channels  and  con- 
nective-tissue spaces,  was  seen  to  be  the  cause  of  diffuse  suppurative 
processes,  while  the  staphylococcus  was  found  by  him  only  in  abscesses 
which  were  circumscribed. 

Rosenbach  took  up  the  work  where  Ogston  left  it,  and,  as  the  fruit 
of  a  number  of  years  of  patient  study  and  research,  published  his 
classical  work  in  1884  ("  Microorganismen  bei  den  Wundinfections 
Krankheiten  des  Meuschen,"  Wiesbaden,  1884),  This  work  must  serve 
as  a  basis  for  all  future  research  on  suppurative  inflammation.  Rosen- 
bach  availed  himself  of  the  advantages  offered  b}^  an  improved  technique 
in  bacteriological  research,  cultivated  the  different  pus-microbes  upon 
solid  nutrient  media,  and  pointed  out  the  difference  in  the  macroscop- 
ical  appearances  of  the  cultures  of  the  different  kinds  of  pus-microbes, 
which  enabled  him  to  differentiate  between  them  hy  the  naked-eye 
appearances  of  the  cultures  upon  the  different  nutrient  substances.  He 
discovered  the  staphylococcus  p^'ogenes  aureus,  the  micrococcus  pyo- 
genes tenuis,  and  three  kinds  of  bacillus  saprogenes. 

Passet  should  be  mentioned  next  in  the  long  list  of  distinguished 
names  of  original  investigators  who  have  made  the  bacteriology  of 
suppuration  a  special  study.  He  discovered  and  described  the  staphy- 
lococcus citreus  and  the  staphylococcus  cereus  albus  and  flavus,and  from 
a  perirectal  abscess  he  cultivated  the  bacillus  pyogenes  foetidus.     The 


INDIRECT    CAUSES   OF    SUPPURATION.  193 

streptococcus  which  he  found  lie  uuiintained  was  different  from  the  one 
described  b}^  Rosenbacli,  as  it  resembled  more  close)}'  the  streptococcus 
of  erysipelas,  but  this  claim  has  not  been  substantiated  b}'  subsequent 
investigations.  The  bacillus  pyocyaneus  was  described  by  Gessard  and 
Charrin.  The  gonococcus,  the  specific  microbe  of  gonorrha\a,  was  dis- 
covered b>'  Neisser  in  1879.  In  our  own  countr^^  the  micro-organisms 
of  pus  have  been  studied  by  such  men  as  Sternberg,  Osier,  Councilman, 
Ernst,  and  Park. 

II.    INDIRECT   CAUSES   OF    SUPPURATION. 

Inflammation  produces  in  the  tissues  conditions  which  must  be 
regarded  as  indirect  causes  of  suppuration.  These  conditions  favor  the 
suppurative  process  by  bringing  the  histological  elements  of  the  inflam- 
matory product  in  a  position  or  relation  to  the  blood-vessels  which 
impairs  or  suspends  their  nutrient  supply.  In  acute  inflammation  the 
connective-tissue  spaces  become  crowded,  in  a  short  time,  with  the 
corpuscular  elements  of  the  blood,  which,  b}'  their  presence  in  such  great 
number,  cause  dilatation  of  these  spaces  and  pressure  upon  the  adjacent 
capillary  vessels,  which  often  result  in  complete  stasis  and  consequently 
arrest  of  blood-suppl}'.  In  consequence  of  suspended  nutrition  arising 
from  vascular  obstruction,  the  leucoc^'tes  undergo  coagulation  necrosis 
and  lose  their  power  of  resistance  to  the  action  of  pathogenic  micro- 
organisms. If  inflammation  attack  the  fixed  tissue-cells  with  an  in- 
tensity short  of  producing  necrosis,  the  cells  proliferate  and  the 
embryonal  cells  thus  produced  constitute  another  source  of  histological 
elements  of  the  inflammatory  product.  If  the  cells  are  produced  in 
excess  of  the  capacity  of  the  inflamed  part  to  supply  them  with  new 
blood-vessels,  the  local  anaemia  thus  created  i)laces  them  in  the  same 
unfavorable  condition  as  the  leucocytes  in  the  crowded  connective-tissue 
spaces,  and  they  are  exposed  to  the  same  risk  of  death  from  malnutrition. 
If,  as  the  result  of  rapid  tissue  proliferation  and  local  ischtemia,  the 
embryonal  cell  become  completely  detached  from  the  matrix  which 
produced  it,  it  is  placed  in  the  worst  condition,  so  far  as  its  vitality 
and  vegetative  capacities  are  concerned,  and  it  readily  succumbs  to 
the  deleterious  action  of  the  pus-microbes.  It  can  be  set  down  as 
a  rule  that  all  conditions,  local  or  general,  which  impair  cell  nutri- 
tion favor  the  suppurative  process.  Suppuration  in  inflammatory  foci 
is  always  observed  first  where  cell  nutrition  is  most  impaired,  hence 
in  the  primar}^  inflammatory  product  among  the  leucocytes  most 
distant  from  capillary  vessels,  and  among  embrj-onal  cells  that  have 
become  isolated  or  occupy  a  place  most  remote  from  the  vascular 
supply. 


194  PRINCIPLES   OF    SURGERY. 

III.    DIRECT   CAUSES   OF    SUPPURATION. 

Clinical  suppiiration  is  caused  by  the  action  of  pus-microbes  on  the 
leucocytes  and  embryonal  cells,  by  which  these  cells,  the  morphological 
elements  of  the  inflammatory  product,  are  converted  into  pus-corpuscles. 
A  number  of  investigators  maintain  that  suppuration  can  be  produced 
artificially  in  animals  by  injecting  into  the  tissues  certain 

Chemical  Pyogenic  Substances. — The  substances  which  have  been 
found  to  possess  the  property  of  exciting  suppurative  inflammation  are 
metallic  mercury,  turpentine,  and  croton-oil.  Councilman  introduced 
turpentine  and  croton-oil  in  aseptic  glass  capsules  into  the  subcutaneous 
connective  tissue  of  animals  under  strict  antiseptic  precautions,  and, 
after  the  wound  had  healed  and  the  capsules  had  become  encysted,  rup- 
tured them  subcutaneousl3\  He  found  that  both  of  these  substances 
caused  a  circumscribed  suppuration.  Uskoff  claimed  that  a  consider- 
able quantity  of  indifferent  su])stances,  sucli  as  milk,  olive-oil,  etc.,  if 
injected  subcutaneously  in  animals,  either  at  once  or  b}'^  repeating  the 
injection  from  time  to  time,  caused  suppuration,  and  that  turpentine 
administered  in  the  same  manner  always  acted  as  a  pj'ogenic  agent. 
Orthmann,  under  Rosenbach's  supervision,  repeated  UskofTs  experi- 
ments, and,  by  resorting  to  more  strict  antiseptic  precautions,  could  not 
verif}^  the  correctness  of  his  conclusions  in  reference  to  the  pus-pro- 
ducing properties  of  indifferent  substances.  His  experiments  with  croton- 
oil,  turpentine,  and  metallic  mercury  always  resulted  in  inflammation 
and  suppuration.  Graw'itz  and  de  Bary  ascertained  that  croton-oil,  when 
injected  in  small  quantities  into  the  subcutaneous  tissues  of  rabbits, 
caused  a  serous  transudation  or  a  fibrinous  exudation,  while  larger  doses 
acted  as  a  caustic,  and  were  only  occasionally  followed  by  suppuration. 
If  they  injected  a  mixture  of  pus-microbes  and  croton-oil  it  always  was 
followed  by  the  formation  of  pus.  The}-  maintained  that  certain  chemi- 
cal substances,  used  in  a  definite  degree  of  concentration,  injected  into 
the  subcutaneous  tissues  of  animals,  prepared  the  tissues  for  the  growth 
of  the  pus-microbes.  From  a  later  series  of  experiments  Grawitz 
became  more  firml}'  convinced  that  aseptic  turpentine,  used  in  sufficient 
quantities,  always  causes  a  suppurative  inflammation  in  the  connective 
tissue.  Inoculations  of  different  nutrient  media  with  pus  produced  bj^ 
turpentine  showed  that  it  contained  no  pus-microbes.  He  also  deter- 
mined that  such  chemical  pus  had  a  destructive  effect  on  pus-microbes. 
Tills  action  of  sterile  pus  he  attributes  not  to  the  presence  of  ptomaines, 
but  to  the  action  of  its  albuminous  constituents.  His  experiments  also 
lead  to  the  important  observation  that  when  gelatin  cultures  are  over- 
saturated  with  album^^u,  or  peptone,  pus-microbes  cease  to  multiply. 
Very  recently  Rosenbach  has  made  a  series  of  experiments  which  has 


DIRECT    CAUSES   OF    SUPPURATION.  195 

convinced  him  tliat  the  chemical  p3'ogenic  substances  which  have  bciii 
mentioned,  when  injected  into  the  tissues  of  animals,  cause  suppuration 
independently  of  the  presence  of  pus-microbes.  Among  those  who, 
from  their  own  experimental  work,  have  come  to  diametricall}^  opposite 
conclusions,  can  be  mentioned  Scheuerlen,  Ruigs,  Natlian,  and  Biondi. 
If  we  consider  for  a  moment  how  difficult  it  is,  in  experimenting  on 
animals  with  indifferent  substances  and  chemical  irritants,  to  procure  for 
the  seat  of  injection  a  perfectl}'  aseptic  condition,  it  is  not  difficult  to 
conceive  that  opinions  still  ditler  in  regard  to  the  immediate  and  essen- 
tial cause  of  suppuration.  Taking  it  for  granted  that  certain  chemical 
pyogenic  substances,  wlien  injected  in  sufficient  quantities  into  the  tissues 
of  animals,  have  the  power  to  produce  suppuration,  inflammation  and 
suppuration  produced  in  such  a  manner  represent  clinically  suppurative 
affections.  Neither  the  inflammation  nor  the  suppuration  following  it 
are  progressive  in  their  character.  The  chemical  substance  produces 
inflammation  over  an  area  which  corresponds  with  the  extent  of  its 
diffusion,  and  the  cellular  elements  of  the  inflammatory  product  are 
converted  into  pus-corpuscles  by  the  destructive  action  of  the  substance 
or  their  protoplasm.  The  whole  course  of  the  artificial  aflection  remains 
aseptic  throughout,  and  the  pus  which  is  produced  is  aseptic  and  sterile, 
— not  clinical,  but  chemical,  pus.  In  suppuration,  as  we  observe  it  at  the 
bedside,  the  direct  cause  which  produced  it  multiplies  in  the  tissues, 
hence  its  tendenc}"  to  become  progressive,  and  from  the  pus  which  is 
produced  the  immediate  and  essential  cause — the  pus-microbes — can  be 
cultivated.  Practicalh',  in  man,  the  occurrence  of  suppuration  from  the 
action  of  pyogenic  chemical  substances  would  be  possible  only  on  the 
surface  of  the  body. 

Pus-Microbes. — That  the  pus-microbes  are  the  immediate  and  essen- 
tial cause  of  suppurative  in/lamination  and  jms  formation  has  been  well 
established  by  clinical  observation  and  experimentation.  Clinical  experi- 
ence during  the  last  twenty  years  has  shown  bej'ond  all  doubt  that  sup- 
puration in  wounds  can  be  prevented  b}'  measures  which  are  calculated 
to  remove,  destro}',  and  exclude  pathogenic  micro-organisms  from  with- 
out. Rosenbach  found  that  in  dogs  and  rabbits  a  small  quantity  of  a 
pure  culture  of  the  staphylococcus  pyogenes  aureus  injected  under  the 
skin  produced  a  most  violent  suppurative  inflammation  ;  cultures  of  the 
staphylococcus  pyogenes  albus  had  the  same  effect.  Cultures  of  the 
streptococcus  p3'ogenes  produced  only  slight  inflammation  in  rabbits, 
while  they  proved  very  fatal  in  mice.  Passet  took  a  pure  culture  of  the 
staphylococcus  pj^ogenes  aureus  the  size  of  a  pea,  grown  upon  potato, 
and  mixed  it  with  1  cubic  centimetre  of  distilled  water.  Of  this  mixture 
he  injected  under  the  skin  of  a  mouse  0.1  cubic  centimetre ;  the  animal 


196  PRINCIPLES   OF    SURGERY. 

recovered.  Another  mouse  was  treated  in  the  same  manner,  but  0.04 
cubic  centimetre  of  a  liquefled-gelatin  culture  was  used,  and  this 
animal  died  in  eighteen  hours.  Cocci  were  found  in  the  blood.  In  rabbits 
and  dogs  a  subcutaneous  injection  of  1  cubic  centimetre  of  liquid-gela- 
tin culture  of  the  aureus  usually  produced  an  abscess  at  the  point  of 
inoculation.  If  the  dose  was  increased  to  5  cubic  centimetres  of  the 
same  culture  the  animals  died  in  from  eighteen  to  twenty  hours.  At 
the  same  time  a  local  inflammation  was  found  at  the  site  of  inoculation. 
In  all  of  tlie  fatal  cases  the  pus-microbe  was  found  in  the  blood.  Of  the 
culture  of  the  streptococcus  pyogenes  it  was  found  necessary  to  inject  a 
considerable  quantity  in  order  to  produce  suppuration.  Liquefied-gela- 
tin  cultures  of  the  staphylococcus  p3^ogenes  aureus  and  albus,  in  doses 
of  1  cubic  centimetre,  injected  into  the  abdominal  cavit}^  of  rabbits,  were 
well  tolerated,  and  death  was  produced  only  when  the  dose  was  increased 
to  from  4  to  6  cubic  centimetres.  Injection  of  cultures  of  the  strepto- 
coccus pyogenes  into  the  peritoneal  cavity  was  even  better  tolerated, 
and  usually  had  to  be  repeated  several  times  before  the  animal  died  of 
septic  peritonitis.  A  needle  dipped  into  a  culture  of  pus-microbes  he 
could  insert  into  points  without  causing  suppuration  ;  but  the  injection 
of  from  0.3  to  0.5  cubic  centimetre  of  a  mixture  of  pus-microbes,  sus- 
pended in  distilled  water,  into  the  hip-joint  of  rabbits,  was  followed  by 
suppurative  arthritis,  rupture  of  the  capsule,  and  diffuse  para-articular 
phlegmonous  inflammation  and  suppuration,  and  often  death  of  the 
animal.  Injection  of  1  or  2  drops  of  a  liquefied-gelatin  culture  of  the 
staph3dococcus  pyogenes  aureus,  or  albus,  into  a  vein  of  a  rabbit  did  not 
produce  any  serious  disturbance,  but  if  the  dose  was  increased  to  from 
0.5  to  1  cubic  centimetre,  it,  as  a  rule,  caused  fatal  disease.  In  such 
cases,  multiple  suppurating  foci  were  found  in  the  kidneys,  liver,  spleen, 
and  lungs,  with  pleuritis  and  peritoneal  eff'usions,  pericarditis,  and 
myocarditis  ;  also  serous  and  purulent  eff'usions  into  joints  and  muscular 
abscesses. 

The  effect  of  inoculation  with  pus-microbes  in  man  is  the  same  as  in 
animals.  Garre  made  a  superficial  abrasion  on  one  of  his  fingers,  and 
applied  a  pure  culture  of  the  staphylococcus  pyogenes  aureus ;  the  only 
symptom  observed  was  a  slight  redness  eighteen  to  twenty-four  hours 
after  the  inoculation.  He  then  made  three  small  incisions,  and  inocu- 
lated himself  with  a  larger  quantity  of  the  culture,  which  was  followed 
by  superficial  suppuration.  Fehleissen  repeated  the  same  experiments 
upon  himself  with  cultures  of  diflTerent  kinds  of  pus-microbes,  and,  if  he 
succeeded  in  causing  suppuration,  this  was  alwa3's  slight.  He  also  found 
minute  doses,  administered  subeutaneously,  harmless  ;  while  larger  doses, 
suspended  in  water,  almost  without  exception  caused  abscesses,  and,  in 


DIRECT    CAUSES    OF    SUPPURATION.  197 

animals,  very  large  doses  produced  death  from  sepsis  before  suppuration 
could  take  place.  Brockhardt  introduced  a  trace  of  a  mixed  culture  of 
staphj'lococcus  aureus  and  albus  into  the  cutis  of  his  left  fore-finger; 
after  forty-eight  hours  a  small  abscess  had  formed,  which  was  opened, 
and  in  the  pus  the  same  microbes  were  demonstrated,  Bumm  injected  a 
pure  culture  of  the  3'ellow  staphylococcus  into  the  subcutaneous  tissue 
of  his  own  arm,  and  into  the  arms  of  two  other  persons.  In  each  in- 
stance an  abscess  developed,  which  varied  from  the  size  of  a  pigeon's 
egg  to  that  of  a  man's  fist,  according  to  the  time  which  elapsed  before 
they  were  opened.  In  the  pus  of  these  abscesses  the  same  pus-microbe 
which  had  been  injected  was  found.  The  above  observations  are  con- 
clusive in  showing  that  pus-microbes  can  be  cultivated  from  the  pus  of 
every  acute  abscess,  and  that,  in  man  and  animals,  the  injection  of  a 
sufficient  quantity  of  a  pure  culture  into  the  tissues  is  followed  by  sup- 
puration ;  and  thus  far  positive  proof  has  been  furnished  of  the  direct 
etiological  relationship  which  exists  between  pus-microbes  and  suppura- 
tion. Rinne  has  recently  published  an  accovmt  of  his  experiments,  and 
his  results  are  somewhat  in  conflict  with  the  authorities  quoted  above. 
He  frequently  failed  to  produce  suppurative  inflammation,  even  when  he 
injected  a  large  quantit}^  of  a  pure  culture,  and  by  repeating  the  injec- 
tion from  time  to  time.  He  is  of  the  opinion  that,  when  the  absorptive 
capacity  of  the  tissues  is  not  diminished,  the  pus-microbes  are  removed 
too  rapidly  to  produce  their  pathogenic  effect.  The  eflect  of  inoculation 
with  pus-microbes  will,  of  course,  always  var}^,  according  to  the  quantity 
of  the  microbes  and  the  local  and  general  susceptibility  of  the  animal 
experimented  on.  Watson  Cheyne  has  shown  most  conclusively  that 
the  number  of  bacteria  introduced  greatl}'  modifies  not  only  the  intensity 
of  the  s^'uiptoms,  but  also  the  character  of  the  disease.  His  experiments 
were  made  with  cultivations  of  Hauser's  proteus  vulgaris.  He  estimated 
that  j^o  cubic  centimetre  of  an  undiluted  culture  of  this  microbe  con- 
tains 225,000,000  bacteria,  and  when  this  quantity  was  injected  into  the 
muscular  tissue  of  a  rabbit  it  produced  speedy  death.  A  quantity  of 
the  same  culture  corresponding  with  -^-^  cubic  centimetre,  administered 
in  the  same  manner,  caused  an  extensive  abscess  at  the  point  of  injection, 
and  death  of  the  animal  in  six  or  eight  weeks.  Doses  of  less  than  -^^-^ 
cubic  centimetre  produced  no  effect, — in  fact,  doses  of  less  than  ^^  to  ^^^ 
cubic  centimetre,  or,  in  other  words,  fewer  than  about  18,000,000  bac- 
teria, seldom  caused  any  positive  result.  The  same  author  found  that  in 
the  case  of  the  staphylococcus  pj'Ogenes  aureus  it  was  necessary  to 
inject  something  like  1,000,000,000  cocci  into  the  muscles  of  rabbits,  in 
order  to  cause  a  rapidly-fatal  result,  while  250,000,000  produced  a  small 
abscess.     In  the  case  of  the  tetanus  bacillus,  death  did  not  occur  in 


198  PRINCIPLES   OF    SURGERY. 

rabbits  when  fewer  than  1000  bacilli  were  introduced.  He  believes,  as 
does  Rinne,  that  the  action  of  the  preformed  ptomaines  on  the  tissues 
modifies  the  result.  It  is,  therefore,  probable  that,  in  the  experiments 
in  which  injection  of  pus-microbes  did  not  produce  suppuration,  an 
insufficient  number  of  active  microbes  were  used,  and  that  where  indif- 
ferent substances  and  chemical  irritants  caused  suppuration  the  implanted 
or  injected  material  was  contaminated,  or  that  infection  at  the  point  of 
injection  occurred  through  the  wound,  or  subsequently  through  the  cir- 
culation. The  latter  method  of  injection  should  always  be  borne  in 
mind  in  cases  where  the  presence  of  an  aseptic  substance  in  the  tissues 
has  apparently  been  the  cause  of  suppuration.  The  tissues  altered  by 
the  action  of  chemical  irritants  constitute  a  foreign  substance,  which 
ma}^  determine  localization  of  microbes  floating  in  the  circulation,  while, 
at  the  same  time,  the  chemical  alterations  which  they  have  caused  in  the 
tissues  have  prepared  a  favorable  soil  for  their  reproduction.  Of  late  a 
number  of  pathologists  have  gone  one  step  farther,  and  maintain  that 
pus-microbes  are  not  the  direct  cause  of  suppuration,  but  that  their 
presence  is  essential  for  the  production  of  ptomaines,  to  which  they 
attribute  p^'ogenic  properties.  If  certain  pyogenic,  aseptic,  chemical 
substances  can  convert  living  cellular  elements  into  pus-corpuscles,  as 
has  been  asserted  upon  good  authority,  we  should  naturally  expect  that 
chemical  substances  produced  by  pus-microbes  in  inflamed  tissue  might 
possess  the  same  pathogenic  propert}^,  and  we  will  briefly  consider  what 
is  known  in  reference  to 

Ptomaines  of  Pus-Microbes  as  a  Cause  of  Suppuration. — Grawitz  and 
de  Bar}',  after  detailing  the  results  of  their  experiments  with  injections 
of  chemical  irritants  in  their  investigations  on  pus  formation,  give  an 
account  of  their  experiments  with  the  ptomaines  of  pus-microbes.  They 
maintain  that  these  ptomaines,  like  chemical  irritants, prepare  the  tissues 
for  the  growth  and  reproduction  of  pus-microbes.  The  action  of  these 
substances  can  be  studied  b}'  injecting  sterilized  cultures  of  pus-microbes, 
in  which  the  only  active  agents  could  be  the  preformed  toxines.  These 
observers  injected  4  cubic  centimetres  of  a  sterilized  culture  of  the 
staphylococcus  pyogenes  aureus  under  the  skin  of  a  dog,  with  the  effect 
of  causing  suppuration.  The  pus  was  examined  for  microbes,  but  none 
were  found.  They  assert  that  the  presence  of  ox3'gen  is  of  the  greatest 
importance  in  the  production  of  ptomaines.  Grawitz  experimented  also 
with  a  pure  preparation  of  cadaverin,  prepared  by  Brieger  from  bacteria. 
Cadaverin  is  a  colorless  fluid,  the  chemical  formula  of  which  is  identical 
with  pentamethylendiomin ;  a  2^-per-cent.  solution  of  this  substance 
destro3'ed  the  staphylococcus  p3'ogenes  aureus  in  an  hour,  and  a  small 
quantity  added  to  a  culture  of  pus-microbes  arrested  further  growth. 


DIRECT   CAUSES   OF    SUPPURATION.  199 

A  solution  absolutely  free  from  microbes,  injected  under  the  skin  of 
animals,  according  to  strength  and  quantity'  used,  produced  cauterization 
or  inflammation,  terminating  in  suppuration  or  inflammatory  oedema, 
followed  by  resolution  and  absorption.  The  pus  produced  by  cadaverin 
contained  no  bacteria  as  long  as  the  skin  remained  intact.  The  injection 
of  a  mixture  of  a  solution  of  cadaverin  and  pus-microbes  was  alwa^'s 
followed  by  a  progressive  phlegmonous  inflammation.  Schenerlen  was 
the  first  to  study  the  local  action  of  ptomaines  on  the  tissues.  He  intro- 
duced into  the  subcutaneous  connective  tissue  of  rabbits  aseptic  glass 
capsules  containing  sterilized  infusion  of  meat.  The  wounds  healed  by 
primary  union.  As  soon  as  the  capsules  had  become  encysted,  he  broke 
off  both  ends  of  the  capsule,  so  as  to  saturate  the  tissues  in  its  imme- 
diate vicinity  with  the  fluid  it  contained.  Three  to  six  weeks  after 
implantation  of  the  capsule  an  incision  was  made  down  to  it,  and  the 
parts  submitted  to  a  thorough  examination.  The  ends  of  the  capsule 
were  always  found  to  contain  a  few  drops  of  thin,  3'ellow  pus,  which, 
under  the  microscope,  showed  all  the  characteristic  appearances  of  that 
fluid.  No  inflammation  of  the  surrounding  tissues.  Cultivation  experi- 
ments with  the  pus  3-ielded  negative  results.  It  is  evident  that  suppura- 
tion in  these  instances  was  caused  by  the  action  of  the  preformed 
ptomaines  on  the  leucoc3'tes  and  embryonal  cells,  and  that  its  extension 
did  not  occur  because  the  cause  did  not  multiply  in  the  tissues.  In 
about  twenty  experiments  the  pus  was  found  only  inside  of  the  cap- 
sule. Weigert  has  repeatedly'  shown  that  the  diflTerence  between  a 
purulent  and  fibrinous  exudation  can  be  readily  demonstrated,  as  the 
former  does  not  coagulate,  although  white  corpuscles  and  plasma  may  be 
present. 

Klemperer  believes  that  this  difference  is  due  to  previous  destruction 
of  fibrogen  in  the  pus  by  the  pus-microbes.  The  putrid-meat  infusion 
used  b}'  Schenerlen  caused  limited  suppuration,  and  on  that  account  it 
must  also  have  possessed  the  propert}'  to  prevent  coagulation.  To  prove 
this  he  made  the  following  experiment :  The  abdomen  of  a  rabbit  was 
opened  while  the  animal  was  under  the  influence  of  chloroform,  and 
blood  was  drawn  directl}'  from  the  aorta  into  a  glass  tube  containing 
putrid  extract  of  meat.  As  the  fluids  graduall^^  became  mixed  the  blood 
assumed  a  brownish-red  color;  coagulation  did  not  occur  for  hours  and 
da}'S,  while  in  the  control  experiments,  with  solution  of  salt,  the  blood 
coagulated  firml}'  after  the  lapse  of  a  few  minutes.  He  next  made  thirty 
cultures  of  the  staphylococcus  pyogenes  aureus  upon  agar-agar  gelatin, 
and  the  same  number  of  cultures  of  the  albus,  and  after  completion  of 
their  growth,  fourteen  days  later,  he  sterilized  them  with  l)oiliiig  water, 
and,  after  shaking  the  fluid,  removed  the  cultures  and  boiled  them  for  a 


200  PRINCIPLES   OF    SURGERY. 

few  minutes,  and  fiufilly  filtered  them  ;  he  thus  obtained  about  150  cubic 
centimetres  of  a  light-yellow  fluid.  This  was  reduced  to  8  cubic  centi- 
metres by  boiling ;  before  using,  the  fluid  was  again  filtered.  The  filtrate 
was  put  in  capsules,  and  after  sealing  their  ends  hermetically  they  were 
inserted  into  the  subcutaneous  connective  tissue  of  animals  with  the 
same  care  as  in  the  preceding  experiments.  The  suppuration  which 
followed  the  breaking  of  the  glass  capsule  in  these  cases  was  again  found 
to  be  limited  to  the  space  with  the  capsule,  being  caused  by  action  of  the 
preformed  ptomaines  on  leucocytes  and  embryonal  cells,  which  found 
their  way  into  the  interior  of  the  glass  capsule. 

The  cadaverin  and  putrescin,  two  ptomaines  prepared  by  Brieger, 
were  next  experimented  with  in  the  same  manner.  In  preventing  coagu- 
lation the  results  were  even  more  striking  than  with  the  former  sub- 
stances. These  experiments  leave  no  doubt  that  ptomaines  derived  from 
pyogenic  bacteria  produce  a  chemical  action  on  leucocytes  and  embryonal 
cells  b}^  which  they  are  converted  into  pus-corpuscles.  The  suppuration 
thus  produced,  however,  never  extends  beyond  the  tissues  which  are 
brought  in  contact  with  them,  and,  therefore,  always  remains  circum- 
scribed. In  this  respect  the  results  of  the  experiments  just  cited  do  not 
correspond  with  suppuration  as  we  observe  it  in  practice^  as  here  from 
the  same  causes,  and  apparently  often  under  the  same  conditions,  the 
process  presents  the  greatest  possible  vaiHations  in  reference  to  its  intensity 
and  extent.  In  one  case  the  suppuration  remains  circumscribed,  result- 
ing in  a  furuncle ;  in  others  the  regional  infection  is  more  extensive,  and 
a  diffuse,  phlegmonous  inflammation  is  the  result;  while  in  the  third  class 
the  local  infection  leads  to  general  systemic  invasion,  and  the  patient  dies 
of  sep)sis  or  pyaemia.  The  clinical  form  of  suppuration  is  noted  for  the 
progressive  character  of  the  infection,  which  is  due  to  the  reproduction 
of  pus-microbes  in  the  tissues  and  the  production  of  ptomaines  pro- 
portionate in  amount  to  the  number  of  microbes  present,  and,  perhaps, 
also  modified  to  a  certain  extent  by  the  character  of  the  soil.  Practi- 
cally, the  matter  remains  the  same  as  before  it  was  known  that  the 
ptomaines  produced  in  the  tissues  b}^  the  p3^ogenic  micro-organisms 
could  cause  suppuration,  as  pus-microbes  must  be  introduced  into  the 
organism,  where  they  must  also  find  an  appropriate  soil  for  their  repro- 
duction, before  ptomaines  can  be  produced  in  suflficient  quantity  to 
account  for  the  occurrence  of  the  clinical  forms  of  suppuration.  To  the 
practical  surgeon  it  is  immaterial  to  know  whether  the  transformation 
of  leucocytes  and  embryonal  cells  is  brought  about  by  the  direct  action 
of  pus-microbes  or  by  the  ptomaines  which  they  produce  in  the  tissues. 

Description  and  Specific  Action  of  the  Different  Pus-Microbes. — The 
microbes  which,  when  present  in  sufficient  number  in  the  tissues,  excite 


DIRECT   CAUSES   OF    SUPPURATION.  201 

suppurative  inflammation  are  called  pus-microbes.  Their  effect  on  the 
cellular  elements  of  the  inflammator}'  product  is  a  specific  one,  convert- 
ing them  into  pus-corpuscles.  Onl}-  such  microbes  will  be  described  here 
which  have  been  cultivated  from  pus,  and  the  specific  action  of  which 
has  been  demonstrated  experimentall}'. 

1.  Staphylococcus  Pyogenes  Aureus. — The  yellow  staph} lococcus  is 
the  microbe  most  frequently  present  in  acute  abscesses.  Under  the 
microscope  it  cannot  be  distinguished  from  the  staphylococcus  pyogenes 
albus. 

It  is  easily  cultivated  upon  gelatin,  agar-agar,  coagulated  blood- 
serum,  and  potato.  The  culture  liquefies  gelatin.  It  grows  best  at  a 
temperature  approaching  that  of  the  blood,  but  can  be  cultivated  at 
30°  C.  It  peptonizes  albumen  and  coagulates  milk.  The  culture  grow\s 
in  the  track  of  the  needle  and  upon  the  surface  of  the  nutrient  medium. 
The  gold-yellow  color  of  the  culture  appears  onl}'  if  the  colon}'  is  ex- 
posed to  atmospheric  air.  Cultures  upon  gelatin  or  agar-agar  retain 
their  virulence  for  a  year  or  more.     This  coccus  is  met  i 

with  frequently  in  acute  circumscribed  abscesses,  osteo-       '^l^i^         2 
myelitis,  pyaemia,  and  ulcerative  endocarditis.  |^  ,;|J 

2.  Staphylococcus    Pyogenes    Albus. — This    pus-      *.s|50s°*    ?}sf^ 
microbe  can  be  distinguished  from  the  yellow  coccus        p^^  49.— micro- 
only  by  the  color  of  the  culture,  which  is  white.    Both      of°stap?yloc'oc^ 
Passet  and  Klebs  have  observed  in  the  white  culture  of      ^^s.   (Rosenbach.) 

1,  culture  twenty-four 

this  coccus  small  yellow  dots,  which,  when  isolated,  Jj^^Jt^'g "'  ™'""^«  '"" 
lost  their  color.  These  authors,  therefore,  consider 
the  yellow  and  white  staph3'lococcus  as  varieties  of  the  same  kind  of 
pus-microbes.  As  other  experimenters  have  not  been  able  to  verily 
these  observations,  we  must  take  it  for  granted  that  the  staphylococcus 
pyogenes  albus  diflTers  from  the  aureus  in  that  it  possesses  no  power 
to  produce  the  same  yellow  color  which  characterizes  the  culture  of  the 
latter.  Its  pathogenic  properties,  both  in  man  and  animals,  are  some- 
what less  than  those  of  the  aureus.  Passet  claims  that  the  white  coccus 
is  more  frequently  found  in  the  suppurative  lesions  in  man  than  the 
yellow,  while  Rosenbach  makes  a  contrarj^  assertion.  The  latter  author 
seldom  found  it  alone  in  pus,  but  more  frequently  associated  with  the 
aureus.  The  cultures  of  both  the  3'ellow  and  white  staphylococcus  ui)on 
gelatin  present  an  irregular  surface,  and  the  margins  are  dotted  with 
minute  globular  projections.  Both  of  these  microbes  liquefj'  gelatin, 
but  agar-agar  and  coagulated  blood-serum  are  not  similarly  affected. 

3.  Staphylococcus  Pyogenes  Citreus. — Found  by  Passet  in  about  10 
per  cent,  of  acute  abscesses  examined.  Like  the  aureus  and  albus,  it 
liquefies  gelatin.     Cocci  singly,  or  in  [tairs,  or  zoogloea.     If  cultivated 


202  PRINCIPLES   OF   SURGERY. 

on  nutrient  gelatin,  or  agar-agar,  a  sulphur  or  lemon-yellow  growth 
develops  after  twenty-four  hours,  which  at  that  time  resembles  the 
aureus,  but  later  does  not  change  into  a  gold-yellow  color.  Like  the 
aureus,  pigmentation  only  takes  place  if  the  culture  is  exposed  to  air. 
According  to  Passet,  its  virulence  is  somewhat  less  than  that  of  the  aureus 
andalbus.  This  statement  has  been  confirmed  by  Cheyne.  When  a  cul- 
ture of  this  pus-microbe  is  injected  under  the  skin  of  mice,  guinea-pigs,  or 
rabbits,  an  abscess  forms,  from  the  pus  of  which  a  culture  of  the  same 
lemon  color  can  be  obtained. 

4.  Staphylococcus  Cereus  Albus. — This  microbe  was  first  discovered 
by  Passet  in  the  pus  of  a  periosteal  abscess  of  a  finger,  as  well  as  in  an 
abscess  of  the  heel.  A  culture  upon  gelatin  is  distinguished  from  that 
of  other  pus-microbes  upon  the  same  nutrient  medium  by  its  forming  a 
white,  slightly-shining  layer,  like  drops  of  white  wax,  with  a  somewhat 
thickened,  irregular  edge.  The  needle-stab  develops  into  a  grayish- 
white,  granular  thread.  In  plate  cultivations,  on  the  first  day,  white 
points  are  observed,  which  spread  themselves  out  on  the  surface  to  spots 
one-half  a  millimetre  in  diameter;  when  cultivated  on  blood-serum,  a 
grayish-white,  slightl3'-shining  streak  develoi)s  ;  and  on  potato  the  cocci 
form  a  layer  which  is  similarly  colored.  This  microbe  is  not  pathogenic 
in  rabbits. 

5.  Staphylococcus  Cereus  Flavus. — Passet  cultivated  this  microbe 
from  the  pus  of  a  case  of  chronic  periostitis  of  the  tibia.  If  cultivated 
on  gelatin,  the  growth,  which  is  at  first  white,  becomes  of  a  citron- 
yellow  color,  resembling  somewhat  yellow  wax,  considerably  darker  than 
the  culture  of  staphylococcus  pyogenes  citreus.  Both  varieties  of 
staph3'lococcus  cereus  are  verj^  rarely  met  witli  in  abscesses,  and  inocula- 
tion experiments  with  them  have  usually  proved  harmless.  Baumgarten 
thinks  it  possible  that  in  cases  where  they  were  found  in  abscesses  the}' 
were  not  the  cause  of  suppuration,  but  occurred  as  an  accidental  inva- 
sion after  thep3'0genic  microbes  had  disappeared. 

6.  Staphyloooccus  Flavescens. — This  microbe  was  found  in  an 
abscess  by  Babes,  and  occupies  an  intermediate  position  between  the 
staphylococcus  pyogenes  aureus  and  albus.  On  gelatin,  the  growth 
forms  a  colorless  layer  and  causes  liquefaction.  It  is  fatal  to  mice, 
sometimes  causing  abscesses,  and,  in  large  doses,  septicaemia. 

7.  MicPGOGOCUS  Pyogenes  Tenuis. — Rosenbach  found  this  micro- 
organism in  a  large  abscess  which  liad  given  rise  to  no  general  s^-mptoms. 
It  is  of  rare  occurrence.  On  agar-agar  it  forms  an  exceedingly'  delicate, 
almost  invisil)le,  white  film.  The  individual  cocci  are  irregular  in  shape, 
and  larger  than  the  staphylococci. 

In  all  cases  in  which  this  microbe  is  tlie  sole  bacterial  cause  of  sup- 


DIRECT    CAUSES   OF   SUPPURATION.  203 

puration,  the  process  appears  to  have  been  unattended  by  any  very  severe 
inflammatory  symptoms,  and  little  or  no  general  febrile  disturbances. 
This  microbe  was  not  found  by  an3^  one  else  but  Rosenbacli  until  February, 
1888,  when  Raskina  isolated  it  from  the  pus  and  organs  in  a  case  of  scar- 
latina complicated  with  pyaemia,  which  resulted  fatallj'  on  the  eighteenth 
day  after  the  beginning  of  the  primary  disease.  At  the  necropsy  mul- 
tiple miliary  abscesses  were  found  in  the  kidne3-s,  at  the  junction  of  the 
cortex  with  the  medullar}'  portion.  From  the  pus  of  these  abscesses  a 
pure  culture  of  the  micrococcns  was  obtained.  Inoculation  experiments 
made  on  rabbits  gave  only  negative  results,  even  though  the  coccus  was 
present  in  the  blood  twenty-four  hours  after  inoculation  ;  hence  it  is 
problematical  as  to  its  being  a  pyogenic  microbe.  Like  the  staphylo- 
coccus cereus,  it  probabl}^  belongs  to  the  so-called  metahiotic  microbes 
of  Garre,  occurring  secondarily  after  suppuration  has  been  established 
by  genuine  pyogenic  microbes. 

8.  Streptococcus  Pyogenes. — Cocci,  somewhat  larger  than  staphy- 
lococci, alwaj's  divide  transversely,  so  that  the}-  arrange  themselves  in 
the  form  of  chains,  which  are  usually  more  or 
less  curved.  /r*'***^ 

•^  V,. 

Fig.  50.— Micrococctjs  Pyogenes  Tenuis,       B'ig.  51.— Microscopic  Picture  of  Strep- 
Cultivated  FROM  Pus  IN  A  Case  of  tococcus  Pyogenes.    {Rosenbach.) 
Empyejia.     i  Rosenbach.) 

The  cocci  also  appear  singly  or  as  diplococci.  Cultures  grow  very 
slowly  on  ordinary  nutrient  media  at  summer  temperature,  but  with 
great  rapidity  at  the  temperature  of  the  body.  Cultivated  in  a  streak 
on  the  surface  of  gelatin  on  a  glass  plate,  this  microbe  forms  at  first 
whitish,  somewhat  transparent,  rounded  spots,  of  the  size  of  small  grains 
of  sand.  On  agar-agar  it  grows  most  luxuriant!}'  at  a  temperature  of 
35°  to  37°  C.  Even  if  the  inoculation  is  made  with  the  point  of  a 
needle  in  a  continuous  line,  the  culture  appears  in  isolated,  small  points. 
In  its  further  growth  the  culture  is  elevated  in  the  centre,  and  presents 
a  pale,  brownish  color,  while  the  periphery  is  flattened,  except  at  the 
extreme  margin,  which  is  again  raised,  and  often  with  a  spotted  appear- 
ance. Still  later,  the  periphery  develops  successive  layers  or  terraces, 
which  were  pointed  out  by  Rosenbach  as  chai'acteristic  macroscopic:il 
features  of  the  cultures  of  this  microbe  upon  solid  nutrient  media.  The 
growth  is  so  slow  that  in  two  or  three  weeks  the  maximum  width  of  the 
culture  streak  is  about  2  or  3  millimetres.  In  a  vacuum  the  strei)to- 
coccus  eftects  peptonization  of  albumen  and  beef.     Subcutaneous  inocu- 


204  PRINCIPLES   OF   SURGERY. 

latioii  in  mice  yields  negative  results  in  about  80  per  cent. ;  sometimes 
a  sliglit  suppuration  follows  at  the  seat  of  puncture,  at  times  the  animal 
dies  without  showing  any  particular  pathological  lesions,  and  no  micro- 
organisms can  be  found  in  any  of  the  internal  organs.  In  the  subcu- 
taneous tissue  of  rabbits  in  small  quantities  they  cause  hyperemia,  red- 
ness, and  slight  swelling,  which  disappear  in  the  course  of  two  or  three 
days ;  when  larger  quantities  are  used,  some  authors  claim  that  they 
produce  small  circumscribed  abscesses.  In  healthy  rabbits  intra-venous 
injection  of  even  a  pure  culture  of  the  streptococcus  causes  no  serious 
symptoms.  If  the  animals  are  debilitated  previously  by  injections  of 
toxic  substances,  death  was  caused  by  rapid  reproduction  of  the  microbe 
in  the  tissues.  If  a  pure  culture  is  injected  into  a  serous  cavity,  it 
causes,  first,  inflammation,  and,  later,  effusion,  which  is  again  absorbed. 
In  the  pus  from  tlie  human  subject  the  streptococcus  is  found  in  about 
40  to  60  per  cent,  of  the  specimens  examined.  This  pus-microbe  invades 
the  tissues  far  in  advance  of  suppuration.  It  is  found  most  frequently 
in  inflammations  following  the  lymphatic  channels.     It  is  also  found  in 


>Su, 


Fig.  52.— Bacillus  Pyogenes  Fcetidus.  Fig.  53.— Bacillus  Pyocyaneus.    X700. 

X790.    {Fluegge.)  (Fluegge.) 

grave  affections,  in  progressive  gangrene.  In  several  cases  of  pyaemia 
cultures  of  the  pus  yielded  a  growth  composed  exclusively  of  the 
streptococcus. 

9.  Bacillus  Pyogenes  Fcetidus. — Passet  found  this  micro-organism 
in  the  pus  of  a  perirectal  abscess.  This  bacillus  possesses  slow  motion, 
its  ends  are  rounded,  and  in  cultures  appears  usually  in  pairs. 

In  stained  specimens  each  bacillus  shows  in  its  interior  one  or  two 
spores.  This  bacillus  grows  on  gelatin,  forming  a  delicate  white  or 
grayish  layer  on  the  surface,  but  causes  no  liquefaction.  When  culti- 
vated on  agar-agar  and  potato  it  has  the  appearance  of  a  light-brown, 
glistening  layer,  which  emits  a  very  offensive  odor.  In  mice  traces  of 
the  culture  do  no  harm  ;  the  injection  of  several  drops  causes  septicaemia. 
Injection  of  about  10  minims  of  the  culture  into  guinea-pigs  causes  an 
abscess,  in  which  the  bacilli  alone  are  found  as  pyogenic  cause  ;  direct 
intra-venous  injection  causes  sepsis. 

10.  Bacillus  Pyocyaneus. — It  has  been  known  for  a  long  time  that 
the  greenish-blue  color  of  the  pus,  occasionally  found  in  the  pus  of  sup- 
purating wounds,  is  due  to  the  presence  of  a  color-producing  microbe. 


PUS.  205 

The  investigations  of  Gessard  and  Charrin,  Ernst,  Fordos,  and  Ledder- 
hose  have  shown  that  this  chromatogenous  microbe  is  the  bacillus 
pyoc3'aneus.  In  the  pus  and  on  solid  culture  media  the  bacilli  appear  in 
pairs,  small  groups,  or,  what  is  more  common,  large  masses,  or  zodgloea. 

This  bacillus  grows  upon  gelatin,  which  liquefies  and  is  stained  a 
greenish  blue.  It  also  grows  vigorously  on  agar-agar  and  potato,  both 
of  these  substances  being  stamed  a  greenish  hue.  In  milk  it  causes 
caseation,  with  subsequent  peptonization  of  the  casein  and  simultaneous 
appearance  of  ammonia,  while  the  coloring  material  a^jpears  on  the 
surface  in  the  form  of  greenish-j^ellow  spots.  Fordos  and  Gessard 
isolated  the  coloring  material  which  this  bacillus  produces,  and  called 
it  pyocj'anin.  It  is  soluble  in  chloroform,  and  from  a  pure  solution 
crystallizes  in  long,  blue  needles. 

Fluegge  asserts  that  this  bacillus  is  devoid  of  pj'ogenic  properties, 
and  appears  only  as  a  harmless  settler  upon  wounds.  Ledderhose,  by 
cultivating  this  bacillus  upon  a  large  scale,  obtained  a  considerable 
quantity  of  pyocyanin,  and  by  chemical  analysis  determined  its  formula 
to  be  C14H14,  NgC.  In  doses  of  1  gramme,  as  muriate  of  pj-ocj'anin, 
injected  into  the  circulation  of  different  animals,  he  observed  no  toxic 
sj-mptoms.  When  a  pure  culture  of  the  bacilli  was  injected,  he  produced 
suppurative  inflammation,  and  attributes  this  result  not  to  the  presence 
of  p3-ocyanin,  but  to  other  as  yet  unknown  phlogistic  and  pyogenic 
substances  elaborated  by  the  bacillus  in  the  tissues. 

IV.   PUS. 

Pus  is  the  liquefied  product  of  suppurative  inflammation.  It  can 
be  defined  as  a  dead  or  dying  tissue  composed  of  cells  with  a  fluid  inter- 
cellular substance.  Pus  is  an  opaque,  creamy,  j^ellowish-white  or 
greenish-white  fluid,  which,  in  a  recent  state,  shows  a  slightl3"-acid 
reaction,  and,  later,  becomes  alkaline  b}-  the  formation  of  ammonia.  If 
it  is  of  a  yellowish  color,  creamy  consistence,  and  odorless,  it  is  the  pus 
bonuni  vel  laudabile  of  the  old  authors.  If  it  is  thin  and  intimatel}' 
mixed  with  blood  it  is  called  sanious  or  ichorous  pus.  If  it  contain 
but  few  pus-corpuscles  and  resemble  serum,  we  speak  of  serous  pus. 
Pus  undergoing  putrefaction  from  the  presence  of  saproplu'tic  bacteria 
is  rendered  fetid,  and  is  then  termed  fetid  pus.  Pus  mixed  with  the 
products  of  tubercular  inflammation  is  designated  tuberculous  pus,  and 
if  mixed  with  the  secretion  of  an  inflamed  mucous  membrane  it  is  defined 
as  muco-pus.  If  pus  is  allowed  to  stand  undisturbed  for  a  number  of 
hours  in  a  test-tube,  it  separates  into  two  parts ;  the  upper,  the  liquid 
portion,  is  the  pus-serum,  or  liquor  puris,  while  the  lower  represents  the 
solid  constituents  of  the  pus,  the  pus-corpuscles. 


206  PRINCIPLES   OF    SURGERY. 

Pus-serum. — The  pus-serum  contains  albumen,  a  compound  called 
pyine,  regarded  by  Mulder  as  identical  with  tritoxide  of  protein,  occa- 
sionally chondrin,  glutin,  and  leucine,  abundant  fatty  matter,  and  inor- 
ganic substances  similar  to  those  dissolved  in  the  liquor  sanguinis. 
Pus-serum  contains  no  oxygen  or  hydrogen,  or  if  present  these  gases  are 
found  only  in  minute  quantities.  On  the  other  hand,  it  contains  nitro- 
gen and  carbonic  acid  in  large  amounts.  It  contains  more  potash  and 
soda  than  blood-serum.  Among  the  albuminous  substances  which  it 
contains  are  paraglobin,  albuminate  of  potash,  serum,  albumen,  and  my- 
osin. Pus-serum,  in  fact,  is  liquor  sanguinis  pZus  soluble  compounds 
which  have  developed  during  the  inflammatory  process  ;  hence  it  contains 
in  solution  the  ptomaines  elaborated  by  the  pus-microbes. 


Fig.  54.    {Koch.) 

1,  white  corpuscles  from  normal  blood  ;  2.  pus-corpuscles  with  cocci  in  their  interior; 
3,  pus-corpuscles  with  bacilli  in  their  interior. 

Pus-corpuscles. — The  histological  sources  of  pus-corpuscles  are  the 
leucocytes  and  embryonal  cells.  In  acute  inflammation  the  process  is  so 
rapid  that  the  pus-corpuscles  are  derived  almost  exclusivel}^  from  leuco- 
cytes. The  conversion  of  a  leucocyte  into  a  pus-corpuscle  in  clinical 
suppuration  is  invariably  accomplished  by  one  or  more  kinds  of  pus- 
microbes  which  have  been  described.  The  pus-microbes  constitute  the 
most  important  morphological  element  of  the  product  of  suppurative  in- 
flammation, being  not  only  diffused  between  the  cells,  but  also  find  their 
way  into  the  interior  of  the  cells. 

All  pus-corpuscles  show  structural  changes  which  indicate  disinte- 
gration. The  leucocytes  present,  as  the  first  evidence  of  transformation 
into  pus-corpuscles,  fragmentation  of  the  nucleus. 

Nuclear  fragmentation  is  an  entirely  different  process  from  karyo- 


PUS. 


207 


kinesis,  as  it  is  not,  like  the  latter,  an  indication  of  cell  reproduction,  but 
of  cell  destruction.  The  nucleus  breaks  up  into  two  to  six  or  more 
fragments,  the  cell-body  still  retaining  its  original  form.  Fragmenta- 
tion of  the  nucleus  is  attended  bj-  other  forms  of  intra-cellular  disinte- 
gration. The  protoplasmic  strings,  which  form  a  living  reticulum  in  the 
interior  of  the  nucleus  and  cell-body,  break  up  and  disintegrate.  The 
embryonal  cells,  which  are  converted  into  pus-corpuscles,  undergo  similar 
retrograde  changes,  as  have  been  described  in  the  leucocyte.  Pus- 
corpuscles  are  not  always  of  the  same  size  and  shape.  Their  size  will 
depend  on  their  histological  source.     Those  derived  from  leucocytes  are 


0^<r 


(1}  > 


Fig.  55.— Fragmentation  of  Nucleus  in  Leucocytes  undergoing  Transformation 
INTO  Pus-COKPUSCLES.    Hartn.  8,  Oc.  iv.     (Landerer.) 

somewhat  uniform  in  size,  while  in  subacute  and  chronic  suppuration 
the  fixed  tissue-cells  in  a  state  of  proliferation  furnish  a  large  percentage 
of  the  pus-corpuscles,  and  consequentlj-  their  size  varies  according  to  the 
tissue-cells  which  undergo  this  change.  As  long  as  the  leucocytes  or 
embryonal  tissue-cells  are  not  completely  destro3-ed  b}^  the  pus-microbes 
or  their  ptomaines,  they  var}'  greatly  in  their  shape. 

The  variation  in  shape  in  fresh  pus-corpuscles  which  have  not  com- 
pletely succumbed  to  the  pus-microbes  is  due  to  their  amoeboid  move- 
ments. If  pus  from  an  acute  abscess  is  examined  in  a  moist  cliamber 
upon  a  warm  slide,  the  amoeboid  movements  of  the  pus-corpuscles  can  be 
observed  for  hours,  provided  the  slide  is  kept  at  a  proper  temperature. 


208 


PRINCIPLES   OF   SURGERY. 


Pus-corpuscles  subjected  to  the  action  of  acetic  acid  clear  up  and 
show  their  fragmented  nucleus  much  plainer.  If  pus-corpuscles  are 
mixed  with  w.ater  they  become  larger  and  hydropic  from  inil)ibition  of 
fluids.      The  round   pus-corpuscles,  according    to    Recklinghausen,  are 


^  -yfm^ 


FiQ.56.— Ptrs  WITH  Staphylococcus. 
X  800.     (Fluegge.) 


Fig.  57 —Pus  with  Streptococcus. 

(Fluec/ge  ) 


dead  leucoc^ytes  or  embryonal  cells  which  have  lost  their  amoeboid  move- 
ments. Liquor  potassa  dissolves  the  pus-corpuscles,  and,  if  added  to 
fluids  containing  pus,  changes  them  into  a  gelatinous  mass.  In  chronic 
abscesses  the  pus-coi'puscles  undergo  molecular  degeneration,  and  such 


(0) 


Fig.  58.     {Billroth-Winiwarter.)     X  400. 

1,  dead  pus-corpuseles ;  2,  various  forms  which  living  pus-corpuscles  assume  by  their  amoeboid  movements ; 
3,  pus-corpuscles  acted  upon  by  acetic  acid  ;  4,  pus-corpuscles  after  addition  of  water. 

pus  under  the  microscope  shows  no  well-formed  corpuscles,  but  a  mass 
of  granular  detritus.  If  the  serum  is  absorbed,  we  speak  of  inspissation 
of  pus.  If  a  wall  of  cicatricial  tissue  form  around  a  collection  of  pus, 
we  say  that  the  pus  has  become  encysted  or  encapsulated. 


CHAPTER  IX. 

Suppuration  {continued). 

CLINICAL    FORMS   OF  SUPPURATION. 

In  reference  to  the  time  required  to  transform  tlie  product  of  inflam- 
mation into  pus,  suppuration  can  be  divided  into  acute,  subacute,  and 
chronic. 

I.  Acute  Suppuration. — In  acute  suppuration  tliewallof  the  capillar}^ 
vessels  is  altered  so  seriously  that  emigration  of  the  colorless  corpuscles 
takes  place  with  such  rapidity  that  within  a  few  hours  the  connective- 
tissue  spaces  are  crowded  with  them,  and  in  a  few  days  the  iuflammatory 
swelling-  presents  indications  of  approaching  suppuration.  The  inflam- 
matory swelling  is  hard  to  the  touch,  and  the  tissues  around  it  become 
oedematous  from  obstruction  to  the  plasma  circulation  within  and  in  the 
immediate  vicinit}'  of  the  inflamed  tissues.  Tlie  hardness  of  the  swell- 
ing is  due  to  the  infiltration  of  tiie  connective  tissue  with  leucocytes.  In 
this  form  of  suppuration  a  central  ischsemic  area  is  established  by  the 
rapid  accumulation  of  leucocytes  in  the  connective-tissue  spaces,  and,  by 
pressure  upon  the  inflamed  and  weakened  capillar}'  vessels,  finally'  leads 
to  complete  stasis.  The  pus-microbes  and  preformed  ptomaines  are 
present  in  such  large  quantities  thnt  liquefaction  of  the  inflammatory 
product  takes  place  within  a  few  days.  The  first  appearances  of  suppu- 
ration are  observed  among  the  cellular  elements  which  appeared  first, 
which  corresponds  to  a  point  in  the  centre  of  the  inflammatorj'  swelling, 
because  at  this  point  tissue  nutrition  has  suffered  most,  and  the  inflam- 
matory product  has  been  exposed  longest  to  the  deleterious  influences  of 
the  pus-microbes  and  their  ptomaines.  The  direct  causes  of  conver- 
sion of  leucocytes  into  pus  corpuscles  are  the  pus-microbes  and  their 
ptomaines,  the  pathogenic  action  of  which  on  the  tissues  results  in  puru- 
lent liquefaction  of  the  inflammatory  product.  Softening  in  the  centre 
of  an  inflammatory  swelling  is  almost  an  unerring  sign  of  approaching 
suppuration.  The  central  suppurating  focus  increases  in  size  by  the  ex- 
tension of  the  process  of  liquefaction  in  all  directions,  the  leucocytes 
saturated  with  the  ptomaines  of  the  pus-microbes  being  rapidl}'  trans- 
formed into  pus-cor[)uscles.  Acute  suppuration  is  always  accompanied 
by  more  or  less  necrosis  of  the  flxed  tissue-cells.     The  acute  cell  necrosis 

"  (209) 


210  PRINCIPLES   OF   StJRGERY. 

is  the  result  of  diminished  blood-supply  and  the  local  toxic  effect  of  the 
ptomaines  of  the  pus-microbes.  Necrosis  occurring  so  constantly  from 
tlie  combined  action  of  these  two  etiological  factors  in  acute  suppura- 
tive osteomyelitis  furnishes  a  good  illustration  of  this.  In  phlegmonous 
inflammation,  from  the  smallest  furuncle  to  the  largest  acute  abscess, 
connective-tissue  necrosis  is  a  constant  occurrence,  following  as  an  un- 
avoidable sequence  of  acute  suppuration.  Acute  suppuration  is  almost 
without  exception  attended  by  a  complexus  of  symptoms,  indicating  the 
entrance  of  phlogistic  substances  from  the  inflamed  tissues  into  the 
general  circulation,  such  as  fever,  headache,  thirst,  loss  of  appetite,  which 
usually  subside  with  the  removal  of  the  primary  cause.  Acute  osteo- 
m3'elitis,  acute  suppurative  inflammation  of  the  large  serous  cavities  and 
joints,  and  phlegmonous  inflammation  of  different  organs  are  excellent  ex- 
amples of  what  is  understood  by  acute  suppuration,  from  an  etiological, 
pathological,  and  clinical  stand-point. 

2.  Subacute  Suppuration. — As  acute  inflammation  may  pass  into  a 
subacute  form,  so  suppuration  may  be  delaj'ed  in  acute  inflammation  for 
days  and  weeks,  if  the  indirect  and  direct  causes  which  are  concerned  in 
the  transformation  of  the  cellular  elements  into  pus-corpuscles  are  present, 
less  in  degree  and  intensity  than  in  acute  suppuration.  The  character 
and  intensity  of  the  primary  microbic  cause  may  determine  a  subacute 
type  of  inflammation  from  the  beginning,  and  suppuration  is  correspond- 
ingly delayed.  In  subacute  suppuration  the  tissues  have  more  time  to 
accommodate  themselves  to  the  presence  of  the  inflammatory  exudate, 
and  hence  tissue  necrosis  is  a  less  constant  occurrence,  and,  if  present, 
it  is  less  extensive.  In  subacute  suppuration,  at  least,  a  part  of  the  pus- 
corpuscles  are  derived  from  the  fixed  tissue-cells  ;  while  in  acute  suppu- 
ration central  liquefaction  of  tlie  inflammatory^  product  often  takes  place 
within  three  or  four  days,  the  same  stage  in  the  subacute  form  is  often 
not  attained  in  as  many  weeks.  As  a  rule,  the  general  sj^mptoms  are 
also  less  severe. 

3.  Chronic  Suppuration. — In  acute  and  subacute  suppuration  the  pus- 
corpuscles  are  derived,  in  the  former  almost  exclusively,  and  in  the  latter 
largely,  from  the  extravasated  leucocytes.  With  few  exceptions  chronic 
suppuration  occurs  as  the  result  of  infection  with  pus-microbes  of  a  pre- 
existing pathological  product  composed  of  granulation  tissue.  In  such 
cases  the  embryonal  tissue  is  the  product  of  a  specific  infiammation 
caused  by  the  presence  of  micro-organisms  which  possess  no  pyogenic 
properties,  but  which  excite  in  the  tissues  a  chronic  inflammation,  the 
product  of  which  consists  of  granulation  tissue.  The  bacillus  of  tuber- 
culosis, the  microbe  of  syphilis,  and  the  actinom3'Ces  are  good  illustra- 
tions of  this  class  of  microbes.      If  a  lesion  caused   by  any  of  these 


CLINICAL   FORMS   OF   SUPPURATION.  211 

microbes  become  the  seat  of  infection  witli  pus-microbes,  tlie  latter  and 
tlieir  ptomaines  are  brought  in  contact  with  cells  which  are  readily  con- 
verted into  pus-corpuscles.  In  chronic  suppuration  the  pus-corpuscles 
are  derived  mostlj^  from  embryonal  cells,  and  consequentl}^  they  show  a 
greater  variety  in  size  and  shape  than  the  pus-corpuscles  found  in  an 
acute  abscess.  Purulent  liquefaction  of  a  mass  of  granulation  tissue  is 
the  characteristic  pathological  feature  of  chronic  suppuration.  Embr3'- 
onal  cells  derived  from  a,ny  of  the  fixed  tissue-cells  are  converted  into 
pus-corpuscles  by  the  pus-microbes  and  their  ptomaines  in  the  same 
manner  as  the  leucocytes  in  an  acute  abscess,  only  that  this  result  is 
attained  more  slowh\  In  the  majorit}'  of  cases  chronic  suppuration  is 
the  result  of  infection  with  pus-microbes  of  a  pre-existing  granulating- 
focus,  the  liquefied  portion  of  which  constitutes  the  contents  of  the 
chronic  abscess.  While  an  acute  abscess  is  often  developed  in  the  course 
of  a  few  days,  and  a  subacute  in  as  many  weeks,  it  maj^  require  as  manj^ 
months  or  years  for  the  products  of  a  specific  inflammation  to  be  trans- 
formed into  a  chronic  abscess. 

Suppuration  in  Wounds. — Infection  of  a  recent  wound  with  a  suffi- 
cient number  of  pus-microbes  is  followed  b}'  suppurative  inflammation, 
which  in  its  local  and  general  manifestations  resembles  phlegmonous 
inflammation  as  it  occurs  without  a  wound.  One  of  the  earliest  evi- 
dences that  such  infection  has  taken  place  is  a  profuse  primarj-  wound- 
secretion.  This  secretion  is  a  mixture  of  blood  and  serum,  and  is 
secreted  in  excess  on  account  of  the  inflamed  capillaries  being  more 
permeable,  and  3'ielding  more  readily  to  the  intra-vascular  pressure.  It 
is  also  possible  that  under  these  circumstances  closure  of  the  lumen  of 
divided  capillaiy  vessels  does  not  take  place  as  promptly  nor  as  com- 
pletelj^  as  in  aseptic  wounds.  Suppurative  inflammation,  when  it  attacks 
a  recent  wound,  commences  upon  its  surface,  with  which  the  microbes 
have  been  brought  in  contact,  and  the  products  of  coagulation  necrosis 
furnish  a  favorable  soil  for  their  growth  and  reproduction.  In  such  a 
wound  the  process  of  granulation  is  either  impeded  or  completely  sus- 
pended until  the  acute  S3'mptoms  have  subsided,  as  the  embr^'onal  cells 
are  converted  into  pus-corpuscles  almost  as  soon  as  the}-  are  formed. 
From  the  surface  of  the  wound  the  inflammation  extends  to  the  deeper 
tissues,  the  extension  being  usually  along  the  connective  tissue,  fascia, 
and  intermuscular  septa.  The  parts  in  the  immediate  vicinity  of  the 
wound  present  the  usual  appearances  of  a  phlegmonous  inflammation. 
The  pus  wliich  forms  first  contains  dead  leucocj'tes,  while  later  the 
embr^'onal  cells  furnish  an  additional  histological  source  for  pus- 
corpuscles.  Granulating  wounds  are  usually  considered  exempt  from 
infection  with  pus-microbes.    While  this  may  be  true  if  the  whole  surface 


212  PRINCIPLES   OF    SURGERY. 

is  covered  with  an  uninterrupted,  intact  layer  of  licalth}-  granulations, it 
is  certainly  not  tlie  case  if  the  granulations  are  in  any  way  injured  or 
diseased.  A  slight  injur}',  as  probing,  ma}'  create  an  infection-atrium, 
through  which  pus-microbes  enter  the  deeper  tissues,  where  the}'  may 
become  the  cause  of  a  suppurative  inflammation.  Under  unfavorable 
vascular  conditions  the  granulations  are  rendered  hydropic,  become 
flabby  and  aufemic, — conditions  which  impair  their  resistance  to  the 
action  of  pus-microbes, — which  then  convert  the  layer  of  embryonal 
cells  most  remote  from  the  blood-supply  into  pus-corpuscles.  Tlie  pre- 
formed ptomaines  injure  the  subjacent  cells,  which  in  turn  undergo  the 
same  fate,  and  thus  an  unhealthy,  infected  granulation  surface  becomes 
the  cause  of  a  secondary  suppuration  in  wounds  which  indefinitely  delays 
the  healing  process.  If  in  a  suppurating  wound  the  pus-microbes  attack 
a  vein  and  produce  a  septic  thrombo-phlebitis,  the  essential  etiological 
condition  for  the  occurrence  of  the  most  dangerous  and  intractable  com- 
plication, pyjemia,  has  been  established. 

SUPPURATIVE   INFLAMMATION    OF   MUCOUS    MEMBRANES. 

Suppurative  inflammation  of  a  mucous  membrane  is  always  preceded 
by  a  catarrhal  stage,  during  which  the  amount  of  the  physiological 
secretion  is  greatly  increased.  Proliferation  of  epithelial  cells  takes 
place  with  such  great  rapidity  that  the  blood-supply  becomes  inadequate, 
when  the  most  superficial  embryonal  cells  readily  succumb  to  the  specific 
action  of  the  pus-microbes  and  are  exfoliated  as  pus-corpuscles,  The 
ptomaines  become  diffused  in  advance  of  the  microbic  invasion,  and,  by 
injuring  the  protoplasm  of  the  cells  more  deeply  located,  prepare  the 
way  for  the  pathogenic  action  of  the  pus-microbes,  and  suppuration  ex- 
tends more  deeply.  In  this  way  ulcers  form,  which  may  remain  super- 
ficial, or  which  may  also  penetrate  deeply  and  result  in  perforation.  The 
products  of  coagulation  necrosis  which  form  upon  the  surface  of  an 
inflamed  mucous  membrane  favor  the  occurrence  and  extension  of  sup- 
purative lesions,  as  they  serve  as  a  means  of  fixation  and  propagation  of 
the  pus-microbes.  Pus  from  a  suppurating  mucous  membrane,  examined 
microscopically,  will  show  pus-corpuscles  derived  from  leucocytes  and 
embryonal,  epithelial,  and  connective-tissue  cells  which  have  become 
detached  before  they  are  converted  into  pus-cells. 

I.  Abscess. — An  abscess  is  a  collection  of  pus  in  the  tissues.  A 
collection  of  pus  in  a  preformed  space,  such  as  the  pleura,  pericardium. 
Fallopian  tubes,  pelves  of  kidneys,  etc.,  although  resulting  from  a  sup- 
purative inflammation  of  the  walls  lining  the  space,  is  by  general  custom 
and  usage  not  called  an  abscess,  but  the  presence  of  pus  in  any  of  these 
organs  is  indicated  by  the  prefix  pyo,  to  which  is  added  the  anatomical 


SUPPURATIVE    INFLAMMATION    OF   MUCOUS    MEMBRANES.       213 

localit}- — thus,  pyo-thorax,  pjo-pericarclium,  pyo-salpinx,  pyo-neplirosis. 
The  formation  of  an  abscess  is  always  preceded  by  a  circumscribed  sup- 
purative inflammation.  Tlie  histological  conditions  which  are  present  at 
the  time  pus  formation  commences  are  characterized  by  a  richness  of 
leucocytes  in  the  connective  tissue  between  the  inflamed  capillary  ves- 
sels and  compression  of  the  pre-existing  tissue-cells  b}'  them  and  the 
transuded  serum. 

Suppuration  commences  at  one  or  more  points  in  the  infiltrated 
area  ;  if  the  latter  is  the  case,  the  different  suppurating  foci  soon  become 
confluent,  forming  an  abscess-cavit}-,  which  increases  in  size  in  all  direc- 
tions, both  by  the  products  of  inflammation  breaking  down  into  pus  and 
by  tlic  iii'.cli:inif:il  jtressure  of  the  exudation  and  transudation  upon  the 


Fig. 


-Infiltration  of  Connective  Tissue  of  Cxttis,  with  Beginning  Suppuration 
IN  THE  Centre.     X  500.     (Billroth-Winiwarter.) 


surrounding  tissues.  The  size  of  the  abscess  is  determined  by  the 
nature  of  the  primary"  cause  of  the  inflammation,  its  location,  and  the 
degree  of  local  and  general  resistance  inherent  in  the  tissues  and 
the  patient.  The  staphylococcus  is  found  more  frequently  in  circum- 
scribed abscesses,  while  the  streptococcus  is  more  prone  to  give  rise  to 
diffuse  purulent  inflltration.  A  suppurating  focus  near  a  surface  is  not 
so  likel}-  to  result  in  a  large  abscess  as  when  it  is  more  deeply'  located,  as 
in  the  former  case  spontaneous  evacuation  in  the  direction  offering  the 
least  resistance  is  an  early  occurrence,  while  in  the  latter  instance  such 
a  termination  is  onl}'  possible  after  the  abscess  has  reached  considerable 
dimensions.  An  abscess  which  develops  in  tissues  debilitated  by  a  con- 
tusion or  some  antecedent  lesions  usuall}'  reaches  greater  dimensions 
than  if  it  occur  in  otherwise  healthy  tissues.     In  patients  whose  strength 


214 


PRINCIPLES   OF    SUKGEKV. 


has  been  impaired  by  old  age,  improper  or  insufficient  food,  intemper- 
ance, mental  anxiety,  or  some  antecedent  acute  or  chronic  ailment,  it  is 
well  known  that  acute  supi)urative  inflammation  manifests  a  great  tend- 
ency to  rapid  extension,  while  a  vigorous,  health}^  body  offers  the  most 
lavorable  conditions  toward  limitation  of  the  suppurative  inflammation. 
While  liquefaction  of  the  inflammatory  product  progresses  from  the 
centre  toward  its  periphery,  the  outer  zone  of  the  inflamed  area  is  in  a 
condition  of  hj'pera'mia  and  active  tissue  proliferation.  The  leucocytes 
beyond  the  infected  area  are  not  converted  into  pus-corpuscles,  and  with 
the  products  of  tissue  proliferation  constitute  an  impermeable  wall, 
beyond  which  infection  cannot  extend.  The  limits  of  the  abscess  is  an 
aseptic  zone  of  inflltration,  clinically  readily  recognized  by  its  hardness 


Fig.  60.— Vessels   (Artificially  Ixjected)   from  Walls  of  an  Abscess  Arti- 
ficially Produced  in  the  Tongue  of  a  Dog.    X  25.    (Billroth- Winiwarter). 

to  the  sense  of  touch — the  so-called  abscess-wail.  As  many  of  the  small 
vessels  in  the  centre  of  the  abscess  are  permanently  destroj'ed,  a  collat- 
eral circulation  is  established  in  the  abscess-wall  and  its  immediate 
vicinity  by  the  formation  of  new  vessels,  as  is  well  shown  in  the  above 
illustration. 

According  to  their  contents,  causes,  and  the  time  which  elapsed 
between  the  commencement  of  the  disease  which  caused  them  and  their 
formation,  abscesses  are  divided  into  acute  and  chronic. 

(a)  Acute  Abscess. — The  acute  or  hot  abscess  is  the  usual  termi- 
nation of  acute  circumscribed  suppurative  inflammation.  Its  favorite 
location  is  in  the  connective  tissue.  It  is  always  caused  by  infection 
with  pus-microbes,  most  frequently  the  staphylococcus.     It  contains  the 


SUPPURATIVE    INFLAMMATION    OF    MUCOUS   MEMBRANES.       '215 

characteristic  yellowish,  cream}-  pus,  the  jyus  honum  et  laudabile  of  the 
old  authors,  and  shreds  of  necrosed  connective  tissue.  It  appears 
within  a  few  da3-s  after  the  commencement  of  the  inflammation  and 
reaches  its  maximum  size  in  a  short  time.  It  is  attended  by  the  typical 
local  and  general  S3  mptoms  which  accompany  acute  suppurative  inflam- 
mation. Acute  abscess  in  the  abdomen  usuallj-  develops  after  perfora- 
tion of  the  intestine  or  one  of  its  appendages;  thus,  perforation  of  the 
gall-bladder  often  gives  rise  to  circumscribed  suppuration  between  the 
liver,  stomach,  and  colon,  and  perforation  of  the  appendix  vermiformis 
in  the  right  iliac  region,  where  the  circumscribed  collection  of  pus  is 
called  a  perityphlitic  abscess.  The  loose  connective  tissue  that 
surrounds  the  kidne}'  is  often  the  seat  of  an  acute  suppurative  inflamma- 
tion, giving  rise  to  a  perinephritic  abscess.  The  connective  tissue  in 
front  of  the  bladder,  the  so-called  cavum  Hetzii,  when  it  is  infected  with 
pus-microbes,  occasionall}^  becomes  the  starting-point  of  an  acute  abscess. 
In  three  cases  of  abscess  in  this  locality-,  that  came  under  my  observation, 
the  infection  was  caused  b}'  a  perforation  of  an  intestine,  and  in  all  of 
them,  after  incision,  scraping,  disinfection,  and  drainage,  a  fsecal  fistula 
developed  subsequently.  Suppurative  parametritis  is  another  instance 
of  acute  abscess,  and  is  usually  caused  by  infection  through  the  uterine 
cavity  or  the  Fallopian  tul)es.  Perirectal  abscesses  following  suppu- 
rative paraproctitis  are  frequently  preceded  hy  localized  rectal  lesions, 
tlirough  which  infection  of  the  connective  tissue  surrounding  the  rectum 
with  pus-microbes  takes  place.  The  manyiei'  of  invasion  often  determines 
the  location  and  character  of  the  abscess.  Thus,  in  suppurative  mastitis, 
the  abscesses  which  are  caused  b}-  staphylococci  always  begin  in  the 
deeper  part  of  the  organ  and  extend  toward  the  surface,  while  in  infec- 
tion with  streptococci  of  the  same  part  the  inflammation  shoots  from 
some  superficial  abrasion  and  first  attacks  the  skin,  whence  the  process 
extends  in  a  central  direction  to  the  deeper  portions  of  the  gland,  where 
suppuration  takes  place  (Cheyne).  This  diflerence  depends  on  the 
manner  of  invasion  of  the  two  microbes.  The  staphylococci  enter  the 
organism  through  the  milk-ducts  and  act  from  their  interior,  whereas 
the  streptococci,  like  the  microbe  of  erysipelas,  enter  the  tissues  through 
the  lymphatic  vessels,  and  their  pathogenic  action  is  primarily  observed 
at  the  surface.  Bumm  excised  a  portion  of  the  wall  of  a  commencing 
abscess  of  the  breast,  and  was  able  to  demonstrate  the  presence  of  staphy- 
lococci in  the  interior  of  the  acini,  and  their  penetration  thence  into  the 
inter-acinous  tissue.  The  phlegmonous  inflammation  of  the  breast 
caused  by  streptococci  takes  place  along  the  course  of  the  l3mphatics, 
and  primarily  involves  the  inter-acinous  connective  tissue. 

Diagnosis. — The    recognition   of  an   acute   abscess  is   usuall}-  not 


216  PRINCIPLKS    UF    SUliGKKY. 

attended  by  any  grc.it  diflloulties.  The  history  of  Jin  attfvck  of  acute 
suppurative  iulhininiation  is  the  first  thing  to  be  talven  into  considera- 
tion. Fever  is  usuall}^  present,  but  if  tlie  abscess  has  been  caused  by 
tlie  micrococcus  pyogenes  tenuis  it  may  be  sliglit,  or  entirel}-  absent. 
The  kjcation  of  the  abscess  has  also  considerable  inihience  on  the 
temperature.  There  is  no  doubt  that  the  same  kind  and  number  of  pus- 
microbes  in  some  tissues  produce  either  a  larger  quantit}'  of  phlogistic 
substances,  or  that  these  in  some  localities  and  certain  tissues  find  a 
more  ready  entrance  into  the  circulation.  Pain  is  always  present,  but  is 
variable  in  intensit}'^  according  to  the  location  of  the  abscess  and  the 
nature  of  its  surroundings.  It  is  severe  if  the  abscess  involves  parts 
freel}'  supplied  with  sensitive  nerves, and  where  the  iiifianimatory  product 
gives  rise  to  an  unusual  degree  of  tension.  Thus,  a  small  abscess  under- 
neath the  deep  fascia  of  a  finger  will  cause  more  suffering  than  a  large 
abscess  in  loose  connective  tissue.  A  beginning  abscess  can  usually  be 
accurately  located  by  ascertaining  the  exact  point  of  tenderness,  on 
making  pressure  with  the  tip  of  a  finger.  If  the  abscess  is  suflScientlj' 
near  the  surface,  fluctuation  can  l)e  felt  as  soon  as  central  liquefaction 
has  occurred.  Redness  of  the  skin  and  diffuse  oedema  over  and  around 
the  abscess  are  important  s3^mptoms,  denoting  the  presence  of  pus. 
Remembering  all  the  S3'mptoms  which  point  to  the  existence  of  abscess, 
in  doubtful  cases  an  absolute  diagnosis  should  not  be  made  by  rel3ung 
upon  any  one  or  all  of  them,  as  b}'  doing  so  serious  blunders  have  been 
and  will  be  made  in  treatment.  Aneurisms  have  been  incised  under  the 
belief  that  they  were  abscesses,  and  the  less  serious  mistake  has  been 
made  of  treating  an  abscess  for  an  aneurism.  The  late  Professor  Gunn, 
who  WHS  "well  known  as  a  careful  and  clever  diagnostician,  incised  a  large 
angioma  in  the  occipital  region,  having  mistaken  it  for  an  abscess.  An 
inflammatory  sw^elling  occurring  in  localities  where  anuerisms  are  liable 
to  be  met  with — that  is,  in  the  course  of  large  blood-vessels — should  be 
examined  with  the  utmost  care  before  an  incision  is  made.  The  most 
dfficult  cases  for  diagnosis  are  the  few  instances  where  a  suppurative 
inflammation  occurs  around  an  aneurismal  sac.  Fortunately,  we  are  in 
possession  of  a  very  simple  diagnostic  expedient,  which,  if  resorted  to, 
as  it  should  be,  in  all  doubtful  cases,  will  enable  the  surgeon,  with 
infallible  certaint}^,  to  ascertain  the  presence  or  absence  of  pus  in  an 
inflammatory  swelling,  and  this  is  the  use  of  the  exploring  syringe.  An 
ordinary  hj-podermic  needle  with  a  long  point  will  answer  the  purpose, 
although  every  surgeon  should  be  supplied  with  an  exploring  sj^ringe 
made  for  this  special  purpose.  The  needle  must  be  rendered  thoroughly 
aseptic  by  heating  it  in  the  flame  of  an  alcohol-lamp.  The  surface  where 
the  i)unctui'e  is  to  be  made  is  thoroughl}'  disinfected,  and  the  needle  is 


SUPPURATn'E    INFLAMMATION    OF    MUCOUS    MEMBRANES.       217 

inserted  somewluat  obliquely  toward  the  centre  ol'  the  swelling  and 
pushed  boldly  forward  in  this  direction  until  resistance  ceases,  which 
is  an  indication  that  it  has  reached  a  cavity  ;  the  piston  of  the  syringe  is 
now  slowlj'  withdrawn  and  the  fluid  aspirated  is  examined  ;  if  it  is  pus 
the  diagnosis  is  made  and  the  needle  is  withdrawn.  If  no  pus  is  found 
the  exploration  is  carried  deeper,  and,  if  necessary,  in  ditlerent  directions 
without  removing  the  needle,  by  making  aspiration  at  different  points  so 
as  to  explore  the  entire  tracks  made  by  the  needle.  If  no  positive 
diagnosis  can  be  made  it  may  become  necessary  to  repeat  this  method 
of  examination  in  a  few  days.  A  rapidly -growing  sarcoma  may  simulate 
a  suppurative  inflammation  so  closely  that  great  care  is  necessary  to 
distinguish  between  these  aflections  before  any  operative  procedure  is 
advised  or  undertaken.  In  exploring  for  pus  in  deep-seated  abscesses 
in  the  abdomen  or  pelvis,  care  should  be  exercised  to  insert  the  needle 
in  such  a  direction,  whenever  this  is  possible,  as  not  to  penetrate  the 
free  peritoneal  cavit}^ ;  whenever  this  cannot  be  done  it  should  be  intro- 
duced in  such  a  manner  that,  after  its  removal,  the  puncture  is  sufficiently 
oblique  to  prevent  the  escape  of  pus.  In  such  cases,  it  is  always  advisa- 
ble to  combine  aspiration  with  exploration.  If  the  tension  in  the  abscess 
is  diminished  b}'  removing  a  portion  of  its  contents  extravasation  is  less 
likeh'  to  occur. 

Treatment. — A  correct  diagnosis  made,  the  old  rule  ubi  j^us  ibi 
evacuo  is  as  applicable  and  wise  to  the  treatment  of  an  acute  abscess  at 
the  present  time  as  it  was  centuries  ago.  Nothing  is  gained  by  expect- 
ant treatment.  The  popular  belief  that  an  abscess  should  be  drawn 
near  the  surface  by  the  use  of  fllthy  poultices  before  it  should  be  opened 
is  fallacious  both  in  theory  and  practice.  An  abscess  is  ready  to  be 
opened  as  soon  as  a  sufficient  quantit}'  of  pus  has  formed  to  constitute 
an  abscess  sufficient  in  size  to  be  recognized  by  the  surgeon  as  such. 
Students  have  generally  been  taught  that  an  abscess  should  be  evacuated 
by  a  free  incision.  This  advice  dates  back  to  the  time  when  antiseptics 
were  not  known  and  tubular  drainage  had  never  been  heard  of.  The 
lajnng  open  of  an  acute  abscess  by  an  extensive  incision  is  no  longer 
necessar}-.  The  indications  in  the  surgical  treatment  of  an  acute  abscess 
are  to  open  it  in  such  a  manner  as  to  secure  perfect  evacuation  and  to 
resort  to  such  means  as  will  prevent  re-accumulation  of  pus.  These  indica- 
tions can  be  fulfilled  much  better  by  making  multiple  small  incisions  and 
establishing  free  drainage  by  the  insertion  of  tubular  drains,  than  by 
making  a  single  long  incision  ;  at  the  same  time,  such  treatment  will 
leave  the  parts  in  better  condition  for  rapid  healing  than  by  the  old- 
fashioned  incisions.  The  incisions  need  never  be  more  than  an  inch  in 
length,  through    which  a    rubber    drainage-tube  the  size    of   the  little 


218  PRINCIPLES   OF    SURGERY. 

finger  can  be  readily  introduced.  Abscesses  uj)  to  the  size  of  an  orange 
do  not  require  more  than  one  incision.  Abscesses  larger  than  this 
should  be  treated  by  through  drainage  wherever  this  is  possible.  In 
deep-seated  abscesses  the  first  incision  is  made  at  a  point  wliere  fiuctua- 
tion  is  most  distinct,  or  in  the  direction  of  the  track  of  the  needle  of 
the  exploring  syringe,  if  the  pus  has  been  located  b^'  the  use  of  this 
instrument.  Instead  of  incising  the  abscess  with  one  stroke  of  the 
knife,  I  always  incise  the  skin  and  fascia  to  the  extent  of  an  inch,  and 
then  wiLli  a  pair  of  sharp-pointed  and  hseinostatic  forceps  I  tunnel  the 
intervening  tissues.  As  soon  as  the  point  of  the  instrument  has  reached 
the  abscess-cavity,  pus  will  escape  along  the  side  of  the  instrument;  the 
handles  of  the  forceps  are  now  locked  and  the  blades  separated  suf- 
ficiently so  that  upon  the  withdrawal  of  the  instrument  the  opening  is 
enlarged  sufficiently  to  introduce  a  drainage-tube  of  requisite  diameter. 
If  counter-openings  are  to  be  made,  the  same  forceps  is  carried  across 
the  abscess-cavity  and  pushed  from  within  outward  at  a  point  where 
drainage  is  most  required,  the  skin  over  the  point  is  cut  with  a  knife,  the 
opening  dilated,  and  a  drainage-tube  drawn  through.  The  surface  over 
the  abscess  and  a  considerable  distance  beyond  it  should  be  shaved  and 
disinfected  before  the  abscess  is  opened.  After  incision  and  drainage 
the  abscess-cavity  is  washed  out  with  a  weak  antiseptic  solution  until 
the  fluid  returns  clear,  when  an  absorbent  antiseptic  dressing  is  applied. 
After  twenty-four  or  forty-eight  hours  the  dressing  is  removed,  the  drain 
shortened,  or,  if  through  drainage  has  been  made,  the  drain  is  cut 
through  in  the  middle  and  each  opening  is  drained  separately.  If  sup- 
puration has  not  ceased  the  cavity  is  again  irrigated.  It  is  seldom  that 
an  abscess-cavity'  heals  without  further  suppuration  after  it  has  been 
incised  and  drained,  even  under  the  strictest  antiseptic  precautions.  The 
inner  lining  of  the  walls  of  the  abscess  remains  infected  with  pus- 
microbes,  and  a  limited  suppuration,  even  in  the  most  favorable  cases, 
continues,  at  least  until  after  the  second  dressing.  The  dressings  should 
be  so  applied  as  to  make  equable  compression,  for  the  purpose  of  keep- 
ing the  surfaces  of  the  abscess-cavity  in  accurate  apposition.  The 
drainage-tubes  are  removed  as  soon  as  suppuration  has  ceased,  when 
healing  of  the  aseptic  cavity  takes  place  by  granulation,  in  the  manner 
described  in  the  healing  of  wounds.  An  important  element  in  the  treat- 
ment of  abscesses  is  to  secure  absolute  rest  for  the  part  affected.  Pa- 
tients suff"ering  from  large  abscesses  should  be  kept  in  bed,  and  in  the 
treatment  of  similar  attections  of  one  of  the  extremities  rest  is  secured 
by  the  application  of  a  well-padded  splint,  which  will  not  only  prove  an 
efficient  means  of  mitigating  pain,  but  will  keep  the  parts  in  a  condition 
most  conducive  to  rapid  healing. 


SUPPURATIVE    INFLAMMATION    OF   MUCOUS   MEMBRANES.       219 

(b)  Chronic  Abscess. — Clironic,  conjestion,  cold,  or,  as  it  is  some- 
times called,  migrating  abscess  can  most  alwa3^s  be  traced  to  some 
specific  clironic  inflammation,  most  frequently  of  a  tubercular  nature. 
What  has  been  called  a  chronic  abscess  is  very  often  no  abscess  at  all. 
In  tuberculous  processes  the  product  of  tissue  proliferation  undergoes 
coagulation  necrosis  and  disintegrates  into  a  granular  mass,  which,  when 
mixed  with  a  sufficient  quantity  of  serum,  forms  an  emulsion  that 
macroscopically  resembles  pus,  but  under  the  microscope  shows  none  of 
the  histological  elements  which  are  found  in  true  pus.  An  abscess  can 
only  be  called  such  if  it  contain  pus.  A  true  chronic  abscess  can  origi- 
nate in  a  tubercular  actinomycotic  or  syphilitic  lesion  when  the  granula- 
tion tissue  is  secondarily  infected  by  the  localization  of  pus-microbes^ 
which  convert  the  embryonal  cells  into  'pus-corpuscles.  Occasionally' 
secondary  infection  with  pus-microbes  of  such  a  granulating  focus  is 
followed  b}-  an  acute  phlegmonous  inflammation,  which  extends  rapidl}^ 
to  the  surrounding  tissues  ;  but  usually  the  suppurating  process  pro- 
gresses slowly-,  and  is  not  attended  by  any  of  the  symptoms  of  acute 
inflammation.  What  has  been  desci'ibed  as  a  cold  abscess  is  a  cavity  con- 
taining the  debris  of  the  product  of  a  tubercular  inflammation,  and  is  in 
communication  icilh  the  p)rimary  lesion.  Such  abscesses  frequently 
appear  at  a  distance  from  the  primary  seat  of  the  disease.  Thus,  tuber- 
culosis of  the  vertebrffi  gives  rise  to  a  lumbar  abscess  if  the  swelling 
appear  in  the  lumbar  region.  It  is  called  a  psoas  abscess  if  the  tuber- 
cular product  gravitate  along  the  course  of  the  psoas  muscle  and  appear 
as  an  abscess  underneath  Poupart's  ligament.  Abscesses  originating  in 
tlie  hip-joint  often,  make  their  first  appearance  over  the  outer  or  inner 
aspect  of  the  thigh,  some  distance  below  the  joint.  Abscesses  originat- 
ing in  the  shoulder-joint  often  wander  a  considerable  distance  awa}'  from 
the  joint,  along  the  course  of  the  biceps  or  triceps  muscle. 

.  Bacteriological  examination  of  the  contents  of  such  abscesses  will 
show  conclusively  whether  they  are  true  pus-containing  abscesses,  or 
whether  they  are  pseudo-abscesses.  If  cultivations  are  made  with  their 
contents,  pus-microbes  will  grow  upon  proper  nutrient  media,  if  it  is  a 
true  media,  while  from  the  contents  of  a  pseudo-abscess  onlj-  the 
microbes  of  the  primary  infection  can  be  cultivated.  The  information 
obtained  1)3-  the  discover}'  of  the  essential  cause  can  be  confirmed  by 
inoculation  experiments.  Cold  abscesses,  as  a  rule,  are  painless,  not 
tender  to  the  touch,  and  give  rise  to  little  or  no  febrile  disturbances. 

Diagnosis. — The  diagnosis  of  a  chronic  abscess  is  based  not  so  much 
upon  the  location,  size,  and  characteristic  features  of  the  swelling  as  a 
careful  consideration  of  the  symptoms  of  the  local  lesion  from  which  it 
started.   Tubercular  affections  of  the  spine  and  hip-joints  are  accompanied 


220  PRINCIPLES   OF    SURGERY. 

by  such  well-defined  symptoms  fit  the  stage  when  abscesses  form 
that  the  primary  lesion  can  be  located  without  much  difIicult3^  A 
chronic  paranephric  abscess  often  develops  in  the  course  of  a  tubercular 
pyelo-nephritis.  A  tubercular  pelvic  abscess  is  frequentl}^  associated 
with  primary  tuberculosis  of  the  Fallopian  tube.  A  chronic  abscess 
often  arises  around  a  tubercular  gland  and  appears,  in  consequence  of 
infection  with  pus-microbes,  as  a  chronic  suppurative  periadenitis.  In 
such  cases  the  gland  itself  has  undergone  caseation,  and  is  often  found 
extensively  separated  from  the  surrounding  tissues  by  the  suppurative 
process.  In  reference  to  the  nature  of  the  swelling  and  the  character  of 
its  contents,  an  exploratorj^  puncture  will  furnish  positive  diagnostic 
information. 

Treatment. — The  indications  for  early  surgical  interference  in  the 
treatment  of  chronic  abscess  are  not  so  urgent  as  in  tlie  acute  variet}'. 
These  abscesses  appear  months  and  often  years  after  the  commencement 
of  the  primary  disease.  While  an  acute  abscess  should  alwa^'s  be  opened 
under  antiseptic  precautions,  it  becomes  a  matter  of  duty  and  conscience 
to  deal  with  a  chronic  abscess  in  a  surgical  way,  on!}-  under  the  strictest 
and  most  elaborate  antiseptic  precautions.  It  is  a  well-known  clinical 
fact  that  when  such  an  abscess  oi^ens  spontaneously,  or  is  incised  in  a 
careless  way,  profuse  suppuration  and  hectic  fever  follow,  with  onl}'^  too 
often  a  speedy  fatal  result  from  septic  infection.  Additional  infection 
with  pus-microbes  results  in  the  destruction  of  the  granulations  which 
line  the  cavit}',  and  the  patient  dies  from  septic  infection.  Unless  the 
surroundings  of  the  patient  admit  of  carrying  out  the  antiseptic  treat- 
ment to  its  fullest  and  most  perfect  extent,  a  chronic. abscess  should  not 
be  evacuated  by  incision.  A  number  of  German  surgeons  have  recently 
advocated  the  treatment  of  such  abscesses  b^^  aspiration  and  iodoform 
injections  in  preference  to  incision  and  drainage.  One  great  difficult}^  in 
evacuating  a  tubercular  abscess  b}'  aspiration  is  the  blocking  of  the 
needle  or  trocar  b3-  shreds  of  necrosed  tissue,  which  often  interferes  with 
complete  evacuation.  A  chronic  abscess  should  always  be  treated  b\^  in- 
cision, if  by  such  procedure  the  primary  lesion  can  be  made  accessible 
to  direct  treatment.  If  such  a  course  is  adopted,  the  incision  is  made 
large  enough  so  that  the  whole  cavity  can  be  thoroughly  scraped  out 
and  all  of  the  infected  tissues  removed.  After  thoroughly  curetting 
the  cavity  is  cleansed  and  disinfected,  and  after  drying  it  is  iodoformized. 
The  wound  is  then  sutured,  drained,  and  treated  on  the  same  principles 
as  a  recent  wound.  The  treatment  of  special  forms  of  chronic  abscess 
will  be  considered  more  in  detail  in  the  chapter  on  Surgical  Tubercu- 
losis. 

2.  Phlegmonous  Inflammation,  with  Suppuration. — Phlegmonous  in- 


SUPPURATIVE    INFLAMMATION    OF    MUCOUS   MEMBRANES.       221 

flammation  with  suppuration  is  clinically  cliaraeterizecl  b}^  rapid  exten- 
sion of  the  disease  without  leading  to  a  circumscribed  collection  of  pus 
or  abscess.  From  the  pus  of  this  form  of  infection  the  streptococcus 
can  be  cultivated  more  frequently  than  the  staphylococcus,  and  in  some 
cases  both  of  these  microbes  are  found  in  the  same  pus.  The  inflamma- 
tion affects  the  connective  tissue,  and  extends  rapidly'  along  intermus- 
cular septa,  fascia,  and  tendon  sheaths.  This  form  of  suppurative 
inflammation  is  prone  to  follow  compound  fractures,  railroad  and  other 
crushing  injuries,  and  all  injuries  attended  by  extensive  contusion  of 
connective  tissue.  The  first  s3"mptoms  usually  appear  within  four  days 
after  the  injury.  The  general  symptoms  are  ushered  in  b_y  a  chill,  fol- 
lowed by  high  temperature  and  rapid  pulse.  The  first  local  symptoms 
ai'e  a  copious,  sanious  discharge  from  the  wound,  and  a  rapidl3'-spreading 
oedema.  The  tissues  are  infiltrated  with  the  same  kind  of  fluid,  and  if 
life  is  prolonged  sufficiently  long  a  diffuse  suppuration  is  inevitable. 
The  symptoms  of  sepsis  in  this  affection  predominate  because  the  pus- 
microbes  have  invaded  an  extensive  area  of  tissue,  and  are  reproduced 
with  great  rapidity  and  gain  entrance  into  the  general  circulation  at  an 
early  stage ;  at  the  same  time  the  necrosed  tissues,  saturated  with  the 
blood}^  serum,  furnish  a  good  soil  for  the  growth  of  putrefactive  bacteria. 
In  most  of  these  cases  the  septic  cellulitis  is  accompanied  by  lymphangitis, 
the  parts  presenting  an  erysipelatous  appearance. 

Treatment. — Phlegmonous  inflammation  of  the  t3pe  just  described 
calls  for  early  and  energetic  treatment  before  suppuration  has  appeared. 
The  pus-microbes  are  present  in  such  quantities  that  the  connective 
tissue  partially  devitalized  by  an  injur^^  becomes  necrosed  from  the 
local  toxic  action  of  the  ptomaines  of  the  pus-microbes.  To  render  such 
wounds  aseptic  is  one  of  the  most  difficult  tasks  in  surgery.  Small  in- 
cisions and  drainage  will  not  accomplish  the  desired  object.  The  in- 
fected tissues  must  be  freely  exposed  b}'  as  many  incisions  as  ma}'  be 
required.  The  secondary  disinfection  in  such  a  case  must  be  regarded 
in  the  light  of  a  capital  oi)eration.  The  patient  should  be  placed  under 
the  influence  of  an  anjesthetic,  the  limb  shaved  and  disinfected,  and  b}' 
large  incisions  the  infected  tissues  must  be  rendered  accessible  to  direct 
means  of  disinfection.  Before  undertaking  the  operation  the  limb 
should  be  rendered  bloodless  by  applying  Esmarch's  constrictor. 

In  compound  fractures  the  tissues  immediately  over  the  fragments 
should  be  incised  sufficiently  so  that  the  fractured  ends  can  be  turned 
out.  The  infected  medullary  tissue  should  be  scooped  out  with  a  sharp 
spoon,  and  all  clots  and  necrosed  tissue  removed;  the  parts  are  then 
thoroughl}^  irrigated  with  corrosive  sublimate  (1  to  1000),  or  carbolic 
acid  (I  to  20),  after  which  the  whole  surface  is  dried  and  brushed  over 


222  TRINCIPLES   OF    SURGERY. 

■with  a  lO-pov-ccMit.  solution  of  cliloride  of  zino.  Pockets  luul  sinuses 
which  cannot  be  reached  with  the  sharp  spoon  can  be  rendered  aseptic 
1>3'  pouring  in  peroxide  of  hydrogen,  whicli,  in  such  cases,  is  a  remedy 
of  great  vaUie.  Tlie  bones  are  then  placed  in  proper  position,  a  numlier 
of  counter-oi)enings  made,  and  a  sufficient  numl)er  of  tubular  drains  in- 
troduced; after  which  a  copious  antiseptic  dressing  is  ai)plied  and  the 
limb  properly  immobilized,  great  care  being  taken  to  prevent  decubitus 
or  gangrene  from  pressure  by  protecting  the  parts  exposed  to  pressure 
witii  antiseptic  cotton. 

During  the  subsequent  treatment  such  a  limb  should  be  slightly 
elevated  and  suspended.  If  after  such  treatment  the  temperature  is  not 
lowered  within  six  hours  and  the  remaining  symi)toms  are  not  improved, 
it  is  evident  that  the  secondary  disinfection  has  not  succeeded  in  obtain- 
ing an  aseptic  condition  of  the  wound.  If  amputation  does  not  appear 
to  be  indicated  at  this  time,  another  effort  should  be  made  to  secure 
nsepticit}'  b}-  resorting  to  pormnnent  irrigation.  Tlie  antiseptic  dressing- 
is  removed  and  not  re-applied.  The  parts  are  covered  with  a  compress 
wrung  out  of  a  ^-per-cent.  solution  of  acetate  of  aluminum,  and  constant 
irrigation  made  with  the  same  solution.  The  simplest  arrangement  for 
constant  irrigation  is  a  reservoir  holding  the  warm  solution  suspended 
over  the  patient's  ])ed,  and  connected  with  the  principal  drainage-tube 
by  means  of  a  rubber  tubing  and  a  glass  tip.  By  siphon  action  the  fluid 
is  conducted  from  the  vessel  to  every  part  of  the  wound.  The  amount 
of  fluid  flowing  through  the  tube  can  be  regulated  hy  compressing  the 
tube  to  the  desired  extent  with  a  clothes-pin.  The  limb  being  suspended, 
the  fluid  is  conducted  away  from  it  into  a  vessel  b}^  means  of  a  sheet  of 
rubber  cloth,  macintosh,  or  gutta-percha. 

Constant  irrigation  with  a  harmless,  non-toxic,  yet  efficient  germi- 
cidal solution  in  these  cases  is  of  the  gi'eatest  value,  as  the  wound-secre- 
tion is  constantly  washed  away,  and,  as  no  accumulation  can  take  place,  the 
danger  of  sepsis  from  products  of  putrefaction  is  greatly  diminished;  at 
tlie  same  time  the  tissues  are  kept  constantl^^  saturated  with  the  solution, 
which  at  last  will  exert  a  potent  inliibitory  influence  upon  the  action  and 
multiplication  of  pus-microbes  in  the  living  tissues.  Should  a  faithful 
attempt  at  obtaining  an  aseptic  condition  by  this  method  of  treatment 
prove  inefficient  after  a  fair  trial,  the  question  of  sacrificing  a  limb,  to 
save,  if  possible,  a  life,  will  present  itself. 

In  the  absence  of  recognizable  secondary  foci  in  distant  organs,  the 
surgeon  will  not  be  able  to  ascertain  whether  a  fatal  form  of  general 
infection  exists  in  a  special  case,  and  it  is  therefore  alwa^^s  justifia1)le  in 
resorting  to  a  mutilating  operation  as  a  last  resort,  provided  the  patient's 
strength  warrants  such  a  procedure.     As  in  cases  of  progressive  gan- 


SUPPURATIVE    INFLAMMATION    OF    MUCOUS    MEMBRANES.       '223 

grene,  so  in  cases  of  progressive  plilegmonous  inflammation,  it  is  ex- 
ceedingly difficult  to  decide  upon  the  exact  location  where  the  amputa- 
tion should  be  made,  as  a  distinct  line  of  demarcation  between  healthy 
and  infected  tissues  is  never  present.  The  only  rule  to  go  by  in  tlie 
selection  of  the  site  of  amputation  is  to  secure  healthy  skin-flaps,  and  to 
make  the  circular  section  of  the  muscular  tissue  above  the  tissues  pre- 
senting macroscopical  evidences  of  infection.  The  condition  of  the 
deep  connective  tissue  furnishes  important  information  concerning  this 
question.  The  infection  is  sure  to  extend  as  far  as  an}^  undermining  or 
sloughing  of  connective  tissue  has  taken  place ;  hence,  amputation  should 
be  done  above  these  limits.  The  general  treatment  of  phlegmonous 
inflammation  is  considered  upon  the  same  principles  as  the  treatment  of 
sepsis  from  other  causes. 

3.  Progressive  Purulent  Infiltration. — This  is  the  purulent  oedema  of 
Pirogoft'.  It  is  a  more  advanced  stage  of  what  has  just  been  described 
as  progressive  phlegmonous  inflammation  with  suppuration.  Purulent 
infiltration  follows  upon  the  heels  of  phlegmonous  inflammation,  and  is, 
consequently,  clinically  also  noted  for  its  progressive  character.  The 
infiltration  is  often  very  extensive,  involving,  in  many  cases,  an  entire 
extremit}'.  It  is  always  attended  b}'  extensive  connective-tissue  necrosis. 
The  pus  burrows  deeply  among  the  muscles  and  detaches  the  skin  over 
a  large  surface.  The  external  appearances  seldom  indicate  the  extent  of 
the  disease.  If  the  skin  is  incised  freely  the  parts  beneath,  the  muscles, 
vessels,  and  nerves,  appear  as  plainly-  as  in  a  dissection  made  to  show  the 
relations  of  these  parts.  Purulent  infiltration  following  progressive 
phlegmonous  inflammation  has  often  been  mistaken  for  erysipelas,  and 
has  been  called  phlegmonous  er3'sipelas.  If  purulent  infilti-ation  com- 
plicate erysipelas,  it  occurs  in  consequence  of  secondary  infection  with 
pus-microhes,  and  not  as  a  result  of  the  action  of  the  streptococcus  of 
erysipelas.  The  gravit}'  of  this  disease  depends  largel}'  upon  the  extent 
of  the  tissues  involved.  If  it  alfect  an  entire  limb  the  danger  to  life  is 
great.     Death  may  occur  from  pyaemia  or  exhaustion. 

Treatment. — The  surgical  treatment  is  the  same  as  in  abscess,  only 
that  tlie  incisions  should  be  made  longer,  two  or  three  inches  in  length, 
in  order  to  enable  the  operator  to  remove  the  necrosed  connective  tissue 
and  to  insert  large  tubular  drains.  After  the  first  incision  is  made  a 
long,  curved,  Pean  forceps  is  introduced,  the  cavity  explored,  and 
counter-openings  made  upon  the  point  of  the  instrument  in  places  where 
drainage  will  be  most  effective.  The  cavity  must  be  drained  at  different 
points  from  one  end  to  the  other  If  the  forceps  is  not  long  enough  to 
reach  both  extremities  it  is  removed  and  inserted  again  into  the  second 
opening,  and  so  on  until  the  cavity  is  thoroughly  drained.    It  is  advisable 


224  PRINCIPLES    OF    SURGERY. 

to  bring  each  drainage-tube  out  of  two  openings  and  secure  each  end  with 
a  safetj'-pin.  In  eases  of  purulent  infiltration  of  an  entire  lower  ex- 
tremity, I  have  often  made  as  man}'  as  twelve  incisions  and  inserted 
half  as  many  drainage-tubes.  After  the  cavity  has  been  thoroughly 
drained,  it  is  washed  out  with  one  of  the  milder  antiseptic  solutions.  An 
excellent  solution  for  this  purpose  is  iodinized  water.  This  can  be  readily 
prepared  b}^  adding  tincture  of  iodine  to  sterilized  water  until  the  solu- 
tion has  the  color  of  sherry  wine.  A  solution  of  this  strength  is  a  valu- 
able antiseptic,  and  can  be  used  repeatedly  and  in  large  quantities  without 
fear  of  causing  intoxication.  I  have  never  succeeded  in  rendering  such 
a  large  suppurative  cavity  aseptic  Avith  one  irrigation,  and  have  conse- 
quently abandoned  the  occlusive  antiseptic  dressings  in  these  cases.  It 
is  much  better  to  apply  a  compress  wrung  out  of  Avarni  salicylated  water 
or  a  1-per-cent.  solution  of  acetate  of  aluminum,  wiiich  can  be  removed 
and  re-applied  every  time  the  cavity  is  irrigated,  which  at  first  should 
be  done  every  four  to  six  hours.  The  warmth  and  moisture  of  the  com- 
press can  be  maintained  by  covering  it  with  gutta-percha  tissue  or  mac- 
intosh cloth.  As  burrowing  of  pus  often  does  not  stop  even  after  efRcient 
drainage  has  been  established,  the  case  should  be  watched  with  great 
care,  and  any  attempt  at  ])urrowing  should  be  promptly  met  by  free 
incision  and  additional  provision  for  drainage.  It  is  always  advisable 
to  support  the  limb  in  proper  position  upon  some  kind  of  a  suspension 
splint,  both  for  the  purpose  of  securing  rest  and  to  prevent  contractures. 
As  soon  as  suppuration  has  nearly  ceased  the  drains  are  shortened  and 
irrigations  made  less  frequently.  It  is  a  consolation  to  know  that  such 
patients,  especially  if  they  are  not  advanced  in  years,  and  free  from  any 
other  disease,  often  rally  and  make  an  excellent  recovery  after  their 
strength  has  been  reduced  to  a  dangerous  extent  and  their  bodies  re- 
duced to  a  skeleton  by  the  prolonged  suppuration  and  septic  fever.  If 
suppuration  is  not  controlled  by  drainage  and  antiseptic  irrigation,  and 
especially  if  the  temperature  and  pulse  indicate  a  continuance  of  absorp- 
tion of  septic  material,  amputation  may  become  an  unavoidable  necessity. 
If  amputation  is  decided  upon,  tlie  deep  incision  must  be  made  beyond 
the  limits  of  the  suppurating  area.  If  the  suppuration  has  extended  as 
far  as  tlie  hip-joint  it  may  become  necessary  to  utilize  for  flaps  the  skin 
which  has  been  undermined,  in  order  to  secure  a  covering  for  the  stump. 
If  such  a  procedure  become  necessary,  the  internal  siirface  of  the  skin- 
flaps  must  be  rendered  aseptic  by  using  the  sharp  spoon  and  scissors  in 
freeing  it  from  infected  tissue.  During  the  whole  course  of  the  disease, 
which  gives  rise  to  purulent  infiltration,  the  patient's  strength  must  be 
supported  by  stimul.ints  and  tonics  and  a  concentrated  nutritious  diet. 
4.  Suppurative  Tendo-Vaginitis. — Another  form  of  rapidly-spreading 


SUPPURATIVE    INFLAMMATION    OF    MUCOUS    MEMBRANES.       225 

inflannufttion  is  suppurative  teiido-vaginitis.  As  the  name  implies,  it 
is  ail  acute  inflammation  of  tendon  sheaths  terminating  in  suppuration. 
It  occurs  most  frequentl}'  in  the  tendon  sheaths  of  the  fingers,  hand,  and 
forearm.  It  develops  usually  from  an  infected  wound  of  tlie  finger  or 
hand,  or  as  a  complication  in  the  different  forms  of  paronychia.  The 
inflammation  travels  along  the  course  of  the  tendon,  starting,  perhaps, 
from  one  of  tlie  tendons  of  a  finger,  extends  to  the  palm  of  the  hand 
underneath  the  annular  ligament  to  the  flexor  muscles  of  the  forearm, 
where  it  often  produces  a  phlegmonous  inflammation  which,  in  the  course 
of  time,  may  involve  the  wliole  forearm.  The  tendons  are  often  destroj'ed, 
and  can  be  pulled  out  after  a  few  weeks, — an  occurrence  Avhich  is  always 
followed  b}"  permanent  functional  impairment  of  the  affected  finger  or  of 
the  whole  hand.  Not  infrequentl}'  suppurative  inflammation  of  a  tendon 
sheath  extends  to  one  or  more  joints  over  which  the  tendon  passes,  caus- 
ing a  complication,  which  often  necessitates  amputation.  This  affection 
is  always  attended  by  severe  pain,  and,  if  extensive,  b}^  grave  constitu- 
tional disturbances.  The  extent  of  the  disease  can  be  ascertained,  ap- 
proximatel}',  at  least,  by  the  external  swelling,  and  especially'  b}'  tlie 
tenderness  along  the  course  of  the  tendon.  Frequently  the  inflammation 
attacks  adjacent  tendon  sheaths  and  the  pus  undermines  the  entire  palmar 
fascia. 

Treatment. — The  surgical  treatment  of  suppurative  tendo-vaginitis 
must  be  thorough  if  it  shall  be  eflficient.  If  it  follow  in  the  course  of  a 
wound,  the  tendon  in  the  wound  is  exposed  ;  if  it  develop  during  an 
attack  of  paronychia,  it  is  laid  bare  by  a  free  incision.  Along  the  course 
of  the  tendon  a  curved  forceps  is  passed,  another  incision  is  made 
down  upon  the  point  of  the  instrument,  and  a  drainnge-tube  is  drawn 
through.  If  the  end  of  the  suppurating  cavity  h;is  not  been  reached  the 
forceps  is  again  introduced  through  the  second  incision  down  to  the 
tendon,  a  third  incision  made  higher  up,  and  another  drainage-tube 
draAvn  through.  These  manoeuvres  are  repeated  until  the  upper  extremity 
of  the  suppurating  cavity  is  reached.  Taking  it  for  granted  that  the 
suppurative  tendo-vaginitis  commenced  in  the  distal  portion  of  the 
middle  finger,  and  has  reached  as  far  as  the  muscles  of  the  forearm,  the 
first  drain  should  reach  as  far  as  the  metacarpo-phalangeal  joint,  the 
second  from  here  to  the  middle  of  the  palm  of  the  hand,  the  third  from 
here  to  above  the  annular  ligament,  and  the  fourth  as  far  as  the  middle 
of  the  forearm,  and  if  suppuration  has  extended  farther  it  will  become 
necessar}^  to  extend  drainage  higher  up  by  another  drain.  If  the  whole 
palmar  fascia  is  undermined,  a  drain  should  be  placed  transversely  across 
the  hand.  If  the  suppuration  has  extended  to  adjacent  tendon  sheaths, 
more  extensive  provision  for  drainage  will  be  required.     The  subsequent 


226  PRINCIPLES  OF   SURGERY. 

treatment  is  the  same  as  in  cases  of  purulent  infiltration.  Necrosed 
tendons  separate  verj^  slowl}',  but  it  is  better  to  leave  their  elimination 
to  the  gi-anulating  process,  as  it  is  ditlicult  to  decide  how  mucli  of  the 
tendon  should  be  removed,  and  its  operative  removal  would  often  require 
large  incisions,  which  would  heal  at  best  only  slowly,  and  the  large 
cicatrix  would  onl}'  add  to  the  functional  impairment  of  the  member. 
From  time  to  time  traction  can  be  made  upon  the  tendon  where  it  is 
exposed,  so  as  to  remove  it  as  soon  as  it  has  become  partially  or  com- 
pletely detached.  Passive  motion  and  massage  must  be  instituted  as 
soon  as  the  abscess  has  healed,  so  as  to  restore  the  function  of  the  limb 
as  far  as  compatible  with  the  existing  condition,  as  not  only  the  affected 
finger  but  the  whole  hand  often  will  be  found  to  have  suffered  seriously 
from  the  attack.  If  one  of  the  principal  tendons  of  a  finger  has  sloughed, 
and  motion  cannot  be  restored,  it  is  advisable  to  immobilize  the  finger 
in  a  slightly-flexed  position,  as  a  curved  finger  is  more  serviceable  than 
a  straight  one.  Suppurative  arthritis  occurring  in  the  course  of  an 
attack  of  tendo-vaginitis  often  necessitates  amputation,  more  especially 
if  it  involve  more  than  one  joint  of  a  finger, 

5.  Paronychia. — Paron3chia,  felon,  whitlow,  are  terms  used  to 
designate  an  abscess  of  a  finger.  All  of  these  terms  should  be  abolished, 
and  abscesses  of  the  finger,  like  of  other  parts,  should  be  called  in  ac- 
cordance with  the  primary  disease  which  caused  them.  Hueter  made  a 
classification  upon  a  strictly  pathological  basis.  The  abscess  may  be 
located  in  the  skin,  and  is  then  a  furuncle  ;  it  may  involve  the  connective 
tissue,  and  is  then  the  product  of  a  phlegmonous  inflammation  ;  it  may 
form  after  an  attack  of  periostitis  or  osteomj-elitis,  or,  finally,  it  may  com- 
mence in  a  joint,  and  is  then  from  the  beginning  a  suppurative  arthritis. 
A  suppurative  tendo-vaginitis,  as  a  primary  affection  of  a  tendon  sheath, 
has  often  been  mistaken  for  an  ordinar}'  felon,  and  treated  as  such,  with 
most  disastrous  results.  Suppurative  tendo-vaginitis  is  frequently  met 
with  as  a  secondary  aflTection  of  the  different  pathological  conditions 
which  give  rise  to  abscess  of  the  fingers.  All  of  the  conditions  which 
have  been  enumerated  as  causes  of  abscess  of  the  fingers  are  attended  b}' 
excruciating  pain,  as  the  anatomical  conditions  necessary  for  the  produc- 
tion of  this  symptom — tension  and  abundant  supply  of  sensitive  nerves — 
:ire  pre-eminent  in  inflammator}'  aflTections  of  the  fingers.  The  pain  is  of 
a  throbbing  character,  and  is  always  aggravated  by  placing  the  hand  in  a 
dependent  position,  as  the  venous  congestion  produced  b}-  this  position 
inerenses  the  swelling,  and  consequentl}- the  tension,  in  the  inflamed  part. 

Treatment. — Volumes  have  been  written  on  the  abortive  treatment 
of  paron3'chia, — the  surest  indication  that  none  of  the  various  means  sug- 
gested have  proved  successful.     Abscesses  of  the  fingers,  as  in  any  other 


SUPPURATIVE    INFLAMMATION    OF    MUCOUS    MEMBRANES.       227 

part  of  the  bod}',  result  onl}'  from  infection  with  pus-raierobes;  hence, 
an}^  measure  which  falls  short  of  effecting  complete  sterilization  at  the 
primary  focus  of  infection  must  necessarily'  fail  in  accomplishing  the 
desired  object.  The  onl}-  rational  treatment  consists  in  the  emplo3'ment 
of  such  measures  as  will  limit  the  extension  of  the  suppuration.  One  of 
the  most  important  elements  in  the  earl}'  treatment  of  a  felon  is  to 
diminish  the  blood-supply  to  the  inflamed  part  by  placing  the  limb  in  an 
elevated  position,  and  by  the  continued  application  of  cold.  The  use  of 
ic6  in  such  a  superficial  inflammation  will  not  onlj^  tend  to  diminish  the 
congestion,  but  at  the  same  time  it  has  a  positive  influence  in  retarding 
the  reproduction  in  the  tissues  of  the  primary  cause — the  pus-microbes. 
Poultices  should  never  be  emplo^'ed.  If  position  and  the  use  of  cold  do 
not  afford  relief,  moist,  hot,  antiseptic  compresses  should  be  applied.  As 
soon  as  pus  has  formed  it  must  be  liberated  by  incision.  The  centre  of 
the  inflammatory  focus  is  accurately  located  by  marking  out  by  pressure 
the  area  of  tenderness,  and  the  incision  is  made  at  this  point  parallel  to 
the  long  axis  of  the  finger.  Scrupulous  care  must  be  exercised  in  ren- 
dering the  whole  surface  of  the  finger  aseptic  before  the  incision  is  made. 
It  is  not  good  practice  to  make  the  incision  invarial)l3'  down  to  the  bone, 
as  the  inflammation  may  not  extend  to  this  depth.  Tlie  incision  is  only 
carried  down  to,  but  not  beyond,  the  suppurating  focus  ;  hence,  it  is  made 
down  to  the  bone  only  if  the  abscess  has  originated  in  a  joint,  or  has 
followed  an  osteomyelitis  or  periostitis  of  a  phalanx.  As  the  wound 
gaps,  free  drainage  is  not  required.  The  abscess  is  washed  out  with  an 
antiseptic  solution,  and  the  finger  dressed  antiseptically.  Suppurative 
arthritis  is  treated  by  through  drainage.  In  osteomyelitis  followed  bj' 
necrosis  the  sequestrum  is  allowed  to  separate  and  is  then  extracted, 
which  can  usually  be  done  after  three  or  four  weeks.  Excellent  results 
are  obtained  after  the  loss  of  a  complete  phalanx,  as  the  bone  is  often 
reproduced  almost  to  perfection  by  the  periosteal  sheath.  Amputation 
only  becomes  necessar}'  in  cases  of  osteomyelitis  aftecting  more  than  one 
phalanx,  complicated  by  suppurative  arthritis  of  the  adjacent  parts. 

6.  Furuncle. — A  furuncle  is  a  small  abscess  of  the  skin.  The  centre 
of  a  furuncle  is  always  occupied  by  a  plug  of  necrosed  connective  tissue, 
vulgarly  called  a  core.  Longard  has  made  a  careful  microscopico- 
baeteriological  examination  of  9  cases  of  furunculosis  in  young  children. 
In  4  of  these  cases  he  found  the  staphylococcus  p3^ogenes  albus  alone,  in 
5  cases  in  combination  with  the  staphylococcus  p3'0genes  aureus.  The 
identity  of  these  microbes  with  those  described  b}'  Rosenbach  was 
demonstrated  b3'  cultivation  and  experiments  on  rabbits.  The  microbes 
were  not  found  in  the  ftecal  discharges  of  the  patients,  but  were  discov- 
ered, in  small  numbers,  in  the  diapers  of  healthj'^,  unclean  children,  as 


228  PRINCIPLES   OF    SURGERY. 

well  as  in  the  diapers  of  those  suliering  from  suppurative  folliculitis. 
He  believes  that  the  pus-microbes  are  the  direct  and  sole  cause  of  the 
affection,  and  that  infection  takes  place  through  the  sweat-glands,  as  the 
microbes  were  found  in  abundance  upon  the  inner  surface  of  the  mem- 
brana  projnna  of  these  glands.  As  soon  as  the  microbes  reach  the 
subcutaneous  connective  tissue  they  produce  suppurative  inflammation. 
Experiments  on  dogs  and  rabbits,  bj^  cutaneous  inoculations  with  pus- 
microbes  cultivated  from  the  furuncles,  produced  a  slight  swelling  and 
redness,  and,  in  some  instances,  the  formation  of  small  pustules.  The 
result  of  these  inoculations  was  always  the  same,  whether  the  cultures 
were  made  from  the  pus  of  a  furuncle,  a  suppurating  wound  that  healed 
without  fever,  or  from  a  i)y8emic  patient.  The  inoculation  experiments 
of  Garrfe,  Brockhart,  and  Bumm,  upon  themselves,  have  been  previousl}' 
referred  to,  and  they  prove  that  many  of  the  circumscribed  suppurative 
affections  of  the  skin  (among  them  furuncle)  are  caused  by  the  direct 
inoculation  with  pus-microbes,  which  enter  the  connective  tissue  either 
through  a  slight  abrasion  or  through  the  glands  of  the  skin.  Furuncles 
often  appear  multiple,  either  in  the  same  region  or  widely  separated  from 
each  other  over  different  parts  of  the  body.  In  such  cases  the  successive 
appearance  of  furuncles  would  tend  to  prove  the  reproduction  and  diffu- 
sion of  the  primary  cause,  the  pus-microbes,  over  the  surface  of  the  bod3\ 
Treatment. — The  prophjdactic  treatment  consists  in  securing  for  the 
skin  a  healthy  condition.  B\'  the  free  use  of  hot  water  and  potash-soap 
the  openings  of  the  glands  of  the  skin  are  cleared  of  accumulation  of 
pus-microbes  and  of  materials  which  might  serve  as  culture  substances. 
In  patients  suffering  from  furuncle,  the  slightest  abrasions  should  be 
treated  with  care,  in  order  to  guard  against  infection.  If  the  general 
health  has  been  impaired,  dietetic  and  medical  treatment  should  be  insti- 
tuted to  correct  the  fault}-  nutrition.  We  have  no  special  internal 
remedies  to  correct  a  supposed  suppurative  diathesis  which  does  not 
exist.  Sulphide  of  calcium,  whicli  has  been  recommended  in  such  strong 
terms,  has  no  influence  either  in  the  prevention  or  cure  of  furuncles. 
With  the  first  appearance  of  a  furuncle,  the  skin  over  and  considerablj'^ 
beyond  it  should  be  disinfected,  and  a  compress  saturated  with  a  weak 
antiseptic  solution  applied.  As  soon  as  pus  appears  it  is  evacuated 
through  a  small  incision,  and  if  the  necrosed  tissue  in  its  centre  has 
become  detached  it  is  extracted.  The  interior  of  the  small  abscess  is 
then  disinfected  and  a  small  antiseptic  dressing  applied.  A  furuncle  is 
an  insignificant  lesion,  but  its  proper  treatment  should  not  be  neglected, 
as  numerous  cases  have  been  reported  where  thrombo-phlebitis,  p3^8emia, 
and  acute  suppurative  osteomyelitis  could  be  traced  to  infection  from  a 
furuncle. 


SUPPURATIVE   INFLAMMATION    OF    MUCOUS   MEMBRANES.       229 

7.  Carbuncle. — A  great  deal  of  confusion  has  been  created  in  the 
minds  of  students  in  reference  to  what  is  really  meant  by  a  carbuncle. 
This  confusion  has  been  brought  about  b^'  the  teachings  of  some  of  our 
text-books,  both  old  and  recent,  which  assert  that  carbuncle  is  alwaj-s 
caused  by  infection  with  the  bacillus  of  anthrax,  while  others  speak  of  a 
less  malignant  form  of  carbuncle  caused  by  suppurative  inflammation. 
Malignant  carbuncle,  or  malignant  pustule,  is  the  anthracic  form  of 
carbuncle,  which  always  starts  from  a  single  centre  of  infection,  and  is 
ajways  attended  by  necrosis  of  the  overlj'ing  skin.  The  ordinary 
carbuncle,  which  is  under  consideration  now,  is  caused  by  infection  with 
pus-microbes,  and  diflers  from  a  furuncle  onh*  in  so  far  that  it  is  made 
up  of  a  number  of  foci  of  suppuration,  which  develop  simultaneously  or 
in  rapid  succession,  and  usually  become  confluent.  A  carbuncle  of  this 
kind  is  in  realit}'  nothing  else,  etiologicall}'^  and  pathologically,  but  a 
group  of  furuncles.  A  section  through  a  carbuncle,  before  extensive 
liquefaction  has  occurred,  will  show  a  number  of  foci  of  suppuration  and 
necrosis,  each  one  of  which,  taken  separately,  would  represent  a  furuncle. 
On  account  of  the  more  extensive  area  of  infection  in  carbuncle  than  in 
furuncle,  the  local  s3'mptoms  are  much  more  severe.  The  tissues  at  an 
early  stage  become  so  extensively  in  filtrated  that  the  carbuncle  feels  as 
hard  as  cartilage.  The  pain,  as  a  rule,  is  very  great.  In  size,  a  carbuncle 
varies  greatly ;  it  is  sometimes  not  larger  than  a  25-cent  piece,  and  it 
may  attain  a  circumference  fully  as  large  as  an  ordinary  soup-plate. 
The  inflammation,  which  first  attacks  the  skin  and  subcutaneous  tissue, 
in  unfavorable  cases,  extends  to  the  deeper  tissues  and  also  travels  in  a 
peripheral  direction.  If  the  carbuncle  is  large,  the  skin  covering  it 
becomes  gangrenous  and  extensive  sloughing  takes  place.  If  the  car- 
buncle is  small,  composed  of  onl}-  three  to  four  centres  of  suppuration, 
the  skin  is  not  destroyed,  with  the  exception,  perhaps,  of  a  very  small 
portion,  corresponding  to  the  apex  of  each  furuncular  focus.  Central 
necrosis  of  the  connective  tissue  in  each  suppurating  focus  invariably 
occurs,  and  if  the  inflammation  is  very  severe  and  extensive  the  whole 
carbuncle  becomes  a  necrotic  mass.  In  mild  cases  the  tissues  between 
the  suppurating  foci  are  preserved,  and  after  the  elimination  of  the 
necrosed  tissue  the  part  presents  a  cribriform  appearance,  each  depres- 
sion indicating  the  exact  position  of  the  former  focus  of  infection. 
Carbuncle  is  met  with  more  frequently  in  persons  advanced  in  3'ears, 
and  attacks  in  preference  such  parts  as  are  most  exposed  to  infection 
from  without,  as  the  neck,  face,  and  hands.  The  dangers  to  life  connected 
with  carbuncle  are  exhaustion  and  septicaemia,  in  the  progressive  form, 
while  thrombo-phlebitis  and  p^'semia  may  occur  as  fatal  complications, 
even  if  the  disease  is  circumscribed  and  the  local  symptoms  not  severe. 


230  PRINCIPLES   OF   SURGERY. 

Diagnosis. — Tlie  differential  diagnosis  consists  in  separating  car- 
buncle frona  furuncle  and  malignant  pustule,  or  antbracic  pustule.  A 
furuncle  presents  only  one  centre  of  suppuration,  is  more  circumscribed, 
more  superficial,  and  not  attended  by  such  marked  infiltration  as  car- 
buncle. Malignant  pustule  is  primarily  not  a  suppurating  lesion,  as  it  is 
caused  by  infection  witli  the  bacillus  of  anthrax,  and  develops  from  one 
point  of  infection  and  gives  rise  to  necrosis  of  the  skin  at  an  early 
age.  Carbuncle  starts,  simultaneously  or  in  rapid  succession,  from  three 
to  a  dozen  or  more  suppurating  foci,  is  attended  by  a  hard  induration 
of  the  surrounding  connective  tissue,  and  gives  rise  always  to  multiple 
foci  of  necrosis  of  the  subcutaneous  connective  tissue. 

Treatment. — The  different  methods  advised  at  various  times  to 
a])ort  a  carbuncle  have  not  proved  more  successful  than  the  means 
suggested  to  check  the  growth  of  a  furuncle.  Very  recently  Beau- 
quinque  has  made  the  assertion  that  a  carbuncle  can  be  aborted  by 
appl^'ing  to  the  part  antiseptics  dissolved  in  alcohol.  He  claims  to  have 
succeeded  in  three  cases  by  applying  tincture  of  iodine.  While  we  have 
no  right  to  question  the  correctness  of  his  diagnosis,  or  the  truth  of  his 
assertions,  it  is  well  known  that  the  same  treatment  has  not  been 
attended  bj^  the  same  satisfactory  results  in  the  hands  of  other  surgeons. 
It  is  difficult  to  conceive  how  the  external  application  of  tincture 
of  iodine  or  any  other  antiseptic  alcoholic  solution  should  have  the 
power  to  destroy  the  pus-microbes  or  prevent  their  reproduction  when 
so  deeply  buried  in  the  tissues.  The  most  potent  agent  to  limit  the 
extension  of  the  inflammation  is  the  continued  application  of  ice.  As 
soon  as  pus  has  formed,  the  different  foci  of  suppuration  should  be 
exposed  to  direct  means  of  disinfection  b}'  incising  the  carbuncle  under 
strict  antiseptic  precautions.  The  old-fashioned  conical  incision  answers 
an  excellent  purpose.  The  necrosed  and  infected  tissues  are  removed 
with  a  sharp  spoon,  and  the  surface  is  disinfected  by  irrigation  with 
a  solution  of  carbolic  acid  or  sublimate  ;  after  which  the  scraped  sur- 
face is  dried  and  touched  with  a  10-per-cent.  solution  of  chloride  of  zinc 
and  the  part  covered  with  an  antiseptic  moist  compress  or  dressed  on 
strict  antiseptic  principles.  If  the  primary  disinfection  does  not  arrest 
further  extension  of  the  disease,  the  whole  surface  shonld  be  deeply 
cauterized  with  the  knife-point  of  Paquelin's  cauter3\  After  cauteri- 
zation a  compress  saturated  with  a  weak  solution  of  corrosive  sublimate 
is  to  be  applied.  With  the  cessation  of  suppuration  granulations  appear, 
when  the  same  treatment  is  to  be  followed  as  in  the  management  of 
granulating  wounds.  Septic  tlirombo-phlebitis  is  announced  b}^  a  well- 
marked  chill,  followed  b}-  the  usual  grave  s3'mptoms  which  attend 
])ya?mia.  If  the  thrombosed  A'ein  can  be  located  in  such  cases  it  should 
be  removed  by  excision,  with  a  faint  hope  that  by  an  early  recourse  to 
this  expedient  a  fatal  form  of  pysemia  may  possibly  be  prevented. 


CHAPTER  X. 

Suppurative  Osteomyelitis. 

Suppurative  inflammation  of  the  marrow  of  bone  is  an  exceed- 
ingly frequent  affection  in  children  and  3-oung  adults.  As  a  primary 
disease  it  is  seldom  met  with  after  the  skeleton  has  become  fully  de- 
veloped. The  form  of  osteom3'elitis  that  will  be  considered  here  is  the 
so-called  spontaneous  variety,  which  occurs  without  direct  exposure  of 
the  medulla  to  infective  micro-organisms  from  without. 

HISTORY. 

Traumatic  osteomyelitis  following  amputation,  compound  fractures, 
or  gunshot  injuries  of  the  bones  has  been  recognized  for  a  long  time  as 
a  distinct  and  serious  wound  complication,  but  osteomyelitis  occurring 
without  such  injuries  Avas  not  understood  until  quite  recentl}'.  We  find 
no  mention  of  this  acute  affection  of  bone  until  1705,  when  J.  L.  Petit 
gave  a  description  of  an  acute  disease  of  the  long  bones  which  corresponds 
with  what  we  now  understand  by  osteom3'^elitis.  Similar  allusions  have 
been  made  to  it  by  Gooch,  Pott,  Cheselden,  Hey,  and  Abernethy,  some 
of  their  descriptions  being  sufficientl}^  accurate  to  enable  us  to  recognize 
the  character  of  the  lesion.  In  1831,  M.  Renaud  published  a  paper  "  On 
Inflammation  of  the  Medullarv  Tissue  of  the  Long  Bones,"  in  which 
he  gives  a  report  of  5  cases  occurring  after  amputation,  all  having 
terminated  fatally. 

Cruveilhier  alludes  to  the  remote  consequence  of  this  affection  when 
he  saj's,  "  The  phlebitis  of  the  bones  is  one  of  the  most  frequent  causes 
of  vjsceral  abscesses  following  wounds  or  surgical  operations  in  which 
the  bones  are  involved."  Roux  credits  Nelaton  with  having  devised  the 
term  osteoni3'elitis  in  1834,  and  having  published  a  brief  account  of  it  in 
1844.  In  1849,  Mr.  Stanley,  in  his  excellent  monograph,  "  On  Diseases 
of  the  Bones,"  gave  an  accurate  account  of  the  spontaneous  varietN' 
under  the  title,  "  Suppuration  in  Bone."  In  1855,  Chassaignac  applied 
the  term  osteom3'elitis  for  the  first  time  to  the  spontaneous  variet3',  re- 
porting at  the  same  time  4  cases  that  came  under  his  own  observation. 
Among  the  surgeons  who  have  increased  our  knowledge  of  the  traumatic 
variet3',  the  names  of  Vallette,  M.  Roux,  Jules  Roux,  Larre3'',  Pirogoff, 
Lidell,  and  Allen  deserve  well-merited  mention.     In  18G5.  Y.  Roser  gave 

(231) 


232  PRINCIPLES   OF    SUKGERY. 

a  coiiii)Iete  resume^  in  tliirt}'  propositions,  of  what  was  tlien  known  con- 
cerning tlio  spontaneous  variety.  On  account  of  tlie  multiplicity  of  the 
bone  ali'ection,  and  the  frequency  with  which  the  joints  are  involved,  he 
called  the  disease  "  pseudo-rheumatism."  The  infectious  origin  of  trau- 
matic osteomyelitis  has  been  recognized  for  a  long  time,  but  the  sponta- 
neous form  was  believed  to  be  purely  inflammatory  until  Luecke  first 
called  attention  to  its  infectious  character.  Demme,  Yolkmann,  Schede, 
and  Hueter  have  added  valuable  contril)utions  to  the  modern  literature  of 
non-traumatic  acute  suppurative  osteom3'elitis.  Pasteur  detected  in  osteo- 
m^elitic  pus  a  mici'obe  which  he  claimed  was  identical  with  the  microbe 
found  in  furuncles ;  hence  he  spoke  of  osteoni3-elitis  as  "  furuncle  of  bone." 
The  bacteriological  and  experimental  researches  of  Koclier,  Rosenbach, 
Passet,  Krause,  and  Kraske  have  established  the  fact  that  non-traumatic 
osteomyelitis,  like  the  traumatic  form,  is  a  suppurative  inflammation  of 
the  medullary  tissue,  caused  invariably  by  infection  with  pus-microbes. 
Primary  suppuration  in  hone  begins  in  the  medullary  tissue ;  hence  it  is 
not  correct  to  syeak  of  a  suppurative  ostitis,  as  is  so  frequently  the  case 
among  English  and  American  authors.  Primary  suppurative  j)eriostitis 
is  an  exceedingly  rare  affection;  consequently,  osteomyelitis  must  be 
considered-  as  the  most  frequent  of  all  inflammatory  diseases  of  bone. 

BACTERIOLOGICAL  AND  EXPERIMENTAL  INVESTIGATIONS. 
Active  suppurative  inflammation  in  bone,  when  it  occurs  independ- 
ently of  an  external  wound,  and  consequently  of  direct  infection,  fur- 
nishes one  of  the  most  interesting,  and,  thanks  to  the  patient  and 
persevering  investigations  of  a  number  of  the  foremost  pathologists,  one 
of  the  best-known  forms  of  purulent  infection.  For  years  it  has  been 
contended,  by  some  who  made  the  etiology  of  acute  osteomyelitis  the 
subject  of  experimentation,  that  it  is  caused  hy  a  specific  microbe  not 
found  in  other  forms  of  suppuration.  Convincing  evidence,  however, 
has  accumulated,  which  seems  to  leave  no  further  doubt  that  the  ordinary 
microbes  of  suppuration  are  the  cause  of  this  form  of  suppurative  in- 
flammation, and  that  the  gravity  of  the  symptoms  which  attended  the 
disease,  as  compared  with  other  suppurative  processes,  is  owing  to  the 
anatomical  location  and  structure  of  the  inflamed  tissues,  rather  than  to 
any  difference  in  the  microbic  cause.  Even  before  the  microbic  cause  of 
acute  osteomyelitis  was  understood,  Kocher  believed  that  infection,  in 
some  cases  at  least,  occurred  through  the  intestinal  canal,  and  made  some 
experiments  to  prove  this  point.  He  produced  subcutaneous  fractures 
artificially  in  dogs,  and  then  fed  the  animals  large  quantities  of  putrid 
materia],  and,  in  some  cases,  succeeded  in  causing  suppuration  at  the 
seat  of  injury.     In  his  clinical  experience  he  also  observed  that  in  many 


BACTERIOLOGICAL   AND    EXPERIMENTAL    INVESTIGATIONS.       233 

cases  of  acute  suppurative   osteom3'elitis  the  premonitory  symptoms 
pointed  to  the  gastro-intestinal  canal  as  the  portio  invasionis. 

Rosenbach  cultivated  the  staphylococcus  from  osteomyelitic  pus  as 
early  as  1881.  In  one  case  the  yellow  and  the  white  staphylococcus 
were  found  together,  in  another  case  the  staph3'lococcus  alone,  while  in 
a  third  case  the  aureus  and  the  streptococcus  pj'ogenes  were  cultivated 
from  the  same  pus.  Rosenbach  produced  the  same  result  in  his  experi- 
ments b}'  injection  of  a  pure  culture  of  pus-microbes  from  a  furuncle  of 
the  lip,  as  Struck  did  with  cultivations  from  the  pus  of  osteomyelitis, 
and  witii  osteomyelitic  pus  injected  into  the  subcutaneous  connective 
tissue  he  produced  an  ordinarj-  abscess.  Recurrent  attacks  of  osteo- 
myelitis, years  after  the  primary  disease  had  been  apparently  cured, 
Rosenbach  explains  b}-  assuming  that  after  the  first  attack  some  of  the 
microbes  remain  in  the  tissues  in  a  latent  condition  until,  at  some  subse- 
quent time,  local  conditions  are  created  which  enable  them  again  to  dis- 
play their  pathogenic  properties.  Struck  obtained  from  the  pus  of  an 
acute  case  of  osteom3-elitis,  upon  gelatin,  an  orange-yellow  culture;  the 
identity'  of  this  culture  with  the  staphjdococcus  pj'ogenes  aureus  was 
soon  generall}'  recognized.  B3-  injecting  a  pure  culture  into  the  circula- 
tion of  animals  whicii  had  been  subjected,  a  few  da^-s  before,  to  injury 
of  bone,  as  contusion  or  fracture,  he  produced  a  suppurative  inflamma- 
tion at  the  seat  of  the  trauma.  Krause  cultivated  from  osteomyelitic 
pus  the  staphjdococcus  pyogenes  aureus  and  albus,  which  he  also  found 
in  the  effusion  of  joints,  when  this  occurred  as  a  complication  of  the 
disease.  Injection  of  a  pure  culture  of  tliese  cocci  into  the  peritoneal 
cavity  of  animals  caused  suppurative  peritonitis.  Intra-venous  injections, 
with  or  without  previous  fracture,  were  followed  most  frequentl}^  by 
suppuration  in  joints  and  muscles.  If  a  bone  was  fractured  subcnta- 
neouslv  before  tlie  injection  was  made,  he  frequentlj^  observed  suppura- 
tion at  the  seat  of  fracture,  and  from  the  pus  the  staphylococcus  could 
again  be  cultivated.  Foci  in  the  kidne3"s  were  alwa3-s  present  in  all  of 
these  experiments.  Miiller  succeeded  in  cultivating  the  staph3dococcus 
P3'0genes  aureus  from  the  3-ellow  granulations  in  cases  of  acute  epiphys- 
ear}-  osteomvelitis.  Rodet  succeeded  in  producing  in  animals  suppura- 
tive osteonu'elitis  l)v  intra-venous  injections  of  pus-microbes,  witliout 
inflicting  an  osseous  injury.  The  suppuration,  whicli  was  generally 
circumscribed,  was  usually  located  near  the  epiphysis;  it  seldom 
involved  any  considerable  portion  of  the  shaft.  lu  man3'  cases  separa- 
tion of  the  epiphysis  and  suppurative  arthritis  of  tiie  adjacent  joint 
occurred.  In  the  most  acute  cases,  the  animal  died  Avithin  twenty-four 
hours,  without  any  appreciable  changes  in  the  bones  being  demonstrable 
at  the  necrops3'.  Young  animals  proved  more  susceptible  to  inoculations. 


284  PRINCIPLES   OF    SURGERY. 

Rodet  believes  that  primaiy  localization  of  the  pus-microbes  takes  place 
in  the  medullary  tissue  at  a  point  close  to  the  epiphyseal  cartilage.  When 
separation  of  the  epiph3'sis  occurred,  the  pathological  fracture  was-always 
found  on  the  side  of  the  diaphysis. 

Rinne,  who  failed  in  producing  metastatic  abscesses  with  pure 
cultures  of  pus-microbes,  rendered  four  rabbits  p3^semic  by  injecting 
osteomyelitic  pus  directly  into  the  venous  circulation.  He  used  the  pus 
taken  from  a  case  of  acute  osteomyelitis  with  grave  symptoms,  and 
diluted  it  with  distilled  water,  and  of  such  a  mixture  he  injected  a  Pravaz 
syringeful  into  one  of  the  auricular  veins  of  four  rabbits.  One  died  in 
twent^'-four  hours,  with  S3'mptoms  of  toxaemia,  and  the  autopsy  showed 
nothing  but  a  beginning  pneumonia  of  left  lung.  The  other  three  animals 
died  seven  to  ten  days  after  the  injection,  and  in  all  of  them  suppurating 
foci  were  found  in  the  kidneys  and  the  muscles  of  the  heart.  No  abscess 
in  muscles  or  suppuration  in  joints.  The  plate  cultures  made  from  the 
pus  used  for  the  experiments  showed  the  staphylococcus  pyogenes  aureus 
and  albus  and  the  bacillus  pyocyaneus.  With  the  exception  of  the 
albus,  all  of  the  microbes  were  also  cultivated  from  the  pus  of  the  metas- 
tatic abscesses.  In  a  later  communication  the  same  author  expresses  the 
opinion  tliat  the  indirect  causes  of  suppurative  osteomyelitis  are  changes 
brought  about  in  the  medullary  tissue  by  the  microbes  and  their 
ptomaines  of  general  febrile  diseases,  such  as  typhus,  scarlatina,  diph- 
theria, etc.,  which  prepare  the  soil  for  the  action  of  pus-microbes,  or  the 
disease  is  produced  by  the  direct  extension  from  a  localized  suppurative 
lesion,  as  a  furuncle,  through  the  l3anphatic  vessels,  or  along  vessel-  or 
nerve-  sheaths  to  the  medullary  tissue. 

Kraske  has  studied,  from  a  clinical  stand-point,  the  manner  of  infec- 
tion in  cases  of  acute  osteomyelitis.  In  one  case  he  could  trace  the 
infection  distinctlj' to  a  furuncle  of  the  lip;  but,  as  a  rule,  he  thinks 
that  infection  takes  place  through  a  wound  or  abrasion  of  the  skin.  In- 
fection through  the  intestinal  canal  he  considers  possible,  but  not  proven  ; 
more  frequently  it  takes  place  through  the  respirator}-  organs,  and  in 
one  case  he  could  locate  the  infection  through  this  route  with  certainty. 
He  asserts  that  recurring  attacks  should  not  alwaj's  be  looked  upon  as 
the  result  of  former  infection,  but  as  a  consequence  of  a  new  infection  of 
the  old  site. 

CAUSES. 

The  essential  exciting  cause  of  suppurative  osteom3-elitis,both  acute 
and  chronic,  is  the  presence  of  one  or  more  varieties  of  pus-microbes. 
Direct  extension  of  a  suppurative  lesion  through  the  medium  of  lym- 
pliatic  vessel-  or  nerve-  sheaths,  as  Rinne  suggests,  may  be  possible,  but 
such  a  direct  connection  between  a  peripheral  suppurating  focus  and  a, 


CAUSES.  235 

central  osseous  lesion  of  a  similar  nature  can  seldom  be  demonstrated. 
Infection  in  most  instances  takes  place  by  pus-viicrohes^  which  have  found 
their  way  into  the  circulation  from  a  suppurating  wound  or  through  the 
respiratory  or  intestinal  mucous  membrane,  and  which  localize  in  the 
medullary  tissue  prejjared  for  their  reception  by  anatomical  peculiarities 
of  the  cap)illary  vessels,  or  by  a  locus  minoris  resistentise,  created  by  an 
injury  or  some  antecedent  pathological  condition.  A  number  of  well- 
authenticated  cases  have  been  reported  where  a  subcutaneous  fracture 
became  the  starting-point  of  an  attack  of  osteomj^elitis  in  patients  who 
suftered  at  the  same  time  from  a  suppurating  wound  in  a  part  distant 
from  the  fracture.  In  such  cases  it  is  reasonable  and  logical  to  assume 
that  pus-microbes  enter  tJie  circulation  and  are  conveyed  by  the  blood-cur- 
rent to  the  seat  of  fracture,  ichere  they  are  arrested  and  find  a  favorable 
soil  for  their  reproduction  and  the  exercise  of  their  pathogenic  properties. 
Such  cases  are  simpl}'  the  counterpart  of  what  has  been  accomplished  b}^ 
experimentation.  Clinical  experieiice  and  experimental  research,  have 
shown  that  pus-microbes  localize  in  preference  near  the  epiiphy seal  line  of 
the  long  bones.  During  the  growth  of  bone  this  region  is  supplied  with 
new,  growing,  and  imperfectl3"-developed  capillar}'  vessels, — a  condition 
which  cannot  fail  in  favoring  localization  of  floating  micro-organisms  in 
this  localit}-.  Xeumann  has  also  called  attention  to  a  peculiarity  of  the 
capillary  vessels  in  the  medullar}'  tissue,  their  calibre  being  four  times 
greater  than  that  of  the  arterial  branches  that  supply  them, — another  im- 
portant anatomical  condition  which  predisposes  to  localization  of  microbes 
in  this  tissue.  Histological  investigation  has  also  shown  that  the  small 
blood-vessels  in  the  medullar}-  tissue  are  devoid  of  a  proper  vessel-wall, 
and  appear  more  like  channels  or  excavations  than  blood-vessels, — another 
condition  wliicli  must  yield  a  potent  influence  in  determining  congestion 
in  these  vessels  and  mural  implantation  of  infected  leucocj-tes  under  the 
action  of  an  exciting  cause  or  causes.  As  Luecke  has  shown,  and  as 
Rinne  again  asserts,  the  medullar}'  tissue  is  prepared  for  the  action  of 
pus-microbes  by  the  causes  which  precipitate  an  attack  of  some  acute 
febrile  affection,  as  variola,  typhoid  fever,  scarlatina,  rubeola,  and  diph- 
theria. Children  and  young  adults  who  have  passed  through  an  attack 
of  any  one  of  these  infectious  diseases  are  strongly  predisposed  to  an 
attack  of  acute  suppurative  osteomyelitis.  Excluding  all  such  influ- 
ences, there  is  still  left  a  large  number  of  cases  where  osteomyelitis 
attacks  persons  otherwise  apparently  in  perfect  health.  My  own  obser- 
vations induce  me  to  attribute  to  exposure  to  cold  an  important  role  as  an 
exciting  cause.  I  do  not  wish  it  to  be  understood  that  exposure  to  cold 
alone  could  ever  result  in  an  attack  of  acute  suppuration  of  the  medul- 
lary tissue.     Pus-microbes   inhabit  persons  in   perfect  health,  and  they 


236  PRINCIPLES   OF   SURGERY. 

do  not  cause  disease  as  long  as  the  circulation  remains  normal,  as  locali- 
zation does  not  take  place  in  the  absence  of  a  proper  soil.  If,  however, 
in  such  a  person  the  circulation  in  the  medullary  tissue  is  disturbed  sud- 
denly, in  conse(inence  of  a  sudden  or  prolonged  chilling  of  the  surface  of 
the  body-congestion,  mural  implantation  and  localization  of  the  floating 
pus-microbes  occur  in  a  locality  which  olfers  the  least  resistance  in  such 
an  emergency,  and  a  suppurative  inflammation  is  established  in  the 
medullary  tissue.  I  have  repeatedly  observed  cases  of  osteomyelitis  in 
bo3's  who,  after  active  exercise,  suddenly  became  chilled  b}'  bathing  in 
cold  water,  or  who,  after  an  exciting  game  of  base-ball,  stretched  them- 
selves out  on  the  cold  ground  to  rest.  A  disturbance  of  the  equilibrium 
of  the  circulation  from  an}'  cause  is  an  important  factor  not  only  in 
precipitating  an  attack  of  acute  osteomyelitis,  but  many  other  local 
infective  processes  in  persons  already  infected  with  the  essential  cause. 

SYMPTOMS. 

Acute  suppurative  osteomyelitis  is  usually  ushered  in  by  a  chill  and 
other  symptoms  indicative  of  the  commencement  of  an  acute  suppura- 
tive affection.  In  some  cases,  even  during  the  earliest  stages,  the  gen- 
eral symptoms  are  out  of  all  proportion  to  the  local  lesion,  presenting  a 
clinical  picture  characteristic  of  intense  septic  intoxication.  I  have 
observed  several  cases  of  multiple  osteomyelitis,  where  the  patients 
passed  into  a  t^-phoid  condition,  muttering  delirium,  dry  tongue,  diar- 
rhoea, and  a  continued  form  of  fever,  with  a  high  temperature  and  rapid 
pulse,  who  died  within  a  week,  before  the  local  disease  had  made  any  con- 
siderable progress.  In  one  of  these  cases  the  patient  was  a  young  lady, 
18  3'ears  of  age,  in  whom  the  disease  affected  both  tibiae,  1  femur,  both 
humeri,  1  clavicle,  and  several  ribs  from  the  very  beginning,  and  the  dis- 
ease proved  fatal  on  the  sixth  day.  In  such  cases  the  prominent  general 
symptoms  are  those  of  a  malignant  form  of  progressive  sepsis.  It  is 
possible  that  the  ptomaines  produced  by  the  pus-microbes  in  the  medul- 
lar}'^ tissue  mny  be  more  virulent,  or  that  they  are  produced  in  larger 
quantities  than  in  suppurative  inflammation  of  other  organs.  Again,  the 
ptomaines  gain  here  more  ready  entrance  into  the  circulation,  as,  at  least 
in  part,  they  are  produced  within  the  blood-vessels,  and  the  extra-vascular 
products  are  forced  rapidly  into  the  circulation  on  account  of  the  unyield- 
ing nature  of  the  tissues  around  the  primary  focus  of  inflammation.  In 
some  cases  of  acute  osteomyelitis  the  actual  development  of  the  disease 
is  preceded  by  premonitory  symptoms,  which  indicate  the  route  tlirough 
which  infection  has  probably  taken  place.  A  preceding  bronchial  ca- 
tarrh would  indicate  the  possibility  that  infection  had  occurred  through 
the  mucous  membrane  of  the  respiratory  organs,  while  infection  through 


SYMPTOMS.  237 

the  intestinal  canal  would  give  rise  to  diarrhoea  as  a  premonitor}-  symp- 
tom. The  local  symptoms  will  be  considered  separately,  as  a  correct 
early  diagnosis  can  onl}'  be  made  by  a  careful  stud}'  of  these,  individually 
and  collective!}'. 

Pain.— Pain  is  one  of  the  earliest  and  constant  symptoms  of  acute 
osteomyelitis.  It  may  be  absent  in  multiple  osteomyelitis,  where  the 
patient  passes  into  a  condition  of  stupor  almost  from  the  beginning. 
The  pain  is  described  by  the  patient  as  being  excruciating,  of  a  boring, 
tearing,  or  throbbing  character.  It  is  not  limited  to  the  area  involved 
by  the  disease,  but  is  often  diffuse,  extending  to  the  adjacent  joint  and 
over  a  considerable  portion  of  the  shaft.  It  is  caused  b}-  the  great 
tension  resulting  from  tlie  pressure  of  the  inflammatory  product  in  a 
tissue  surrounded  by  an  un3Melding  case  of  compact  bone.  Pain  in- 
creases as  the  exudation  becomes  more  abundant,  and  is  diminished  or 
subsides  almost  completely  with  the  escape  of  the  inflammatory  product 
from  the  interior  of  the  bone  into  the  surrounding  soft  tissues.  Sudden 
diminution  of  pain  is  almost  a  certain  indication  that  perforation  of  the 
bone  has  occurred,  and  that  the  pus  has  escaped  into  the  paraperiosteal 
tissues.  The  location  of  pain  sliould  be  carefull}'  inquired  into,  as  in 
multiple  osteom^'elitis  this  symptom  will  locate,  at  an  early  time,  the 
number  and  location  of  bones  affected.  In  multiple  osteom^-elitis  the 
disease  ma}^  appear  simultaneousl}^  in  several  bones  far  apart,  or  the 
disease  appears  in  one  bone  first,  and  other  bones  are  attacked  later 
successivelv.  The  appearance  of  pain  in  a  new  locality  is  generally  an 
indication  that  another  bone  has  become  involved. 

Tenderness. — The  patient  is  very  seldom  able  to  locate  accuratel}^ 
the  primary  focus  of  the  disease  in  an  inflamed  bone,  as  the  pain  is 
diffuse,  but  the  pain  caused  b}^  pressure  will  enable  the  surgeon  to  locate 
the  primary  focus  within  the  bone  with  accuracy,  even  before  an}'  ex- 
ternal swelling  has  appeared.  During  the  first  few  days  the  area  of 
tenderness  will  correspond  to  the  extent  of  the  disease  in  the  interior  of 
the  hone,  and  the  centre  of  this  area  will  correspond  to  the  primary  focus 
of  the  inflammation.  Tenderness  is  most  acute  where  the  disease  has 
approached  nearest  the  surface  of  the  bone,  and  by  this  means  the  sur- 
geon locates  the  site  for  early  operation.  Tenderness  is  caused  by  the 
secondary  periostitis.  In  osteomyelitis  of  the  long  bones  this  symptom 
appears  first  near  one  of  the  epiphyses,  and  extends  later  toward  the 
shaft  of  the  bone  as  the  periostitis  ascends  or  descends  in  that 
direction. 

Swelling. — The  absence  of  external  swelling  during  the  first  few 
days  of  an  attack  of  acute  osteomyelitis  has  often  given  rise  to  mistakes 
in  diagnosis.     As  the  primary  inflammation  is  located  in  the  interior  of 


238  PRINCIPLES   OF    SURGERY. 

a  bone,  external  swelling  is  absent  until  the  inflammation  has  extended 
to  the  surrounding  soft  tissues.  With  the  appearance  of  the  secondary 
periostitis  swelling  occurs,  which  at  first  can  be  felt  as  a  hard  induration, 
soon  followed  b}^  oedema  and  deep-seated  fluctuation.  The  rapid  local 
diflTusion  of  the  process  is  largely  due  to  the  unyielding  nature  of  the 
tissues  around  the  primary  focns,  and  to  the  fact  that  the  blood-vessels 
are  directly'  concerned  in  the  extension  of  the  process  by  becoming  the 
channels  for  the  dill'usion  of  the  septic  infection,  their  contents  forming 
a  nutrient  medium  for  the  pus-microbes,  Thrombo-phlebitis  is  a  con- 
stant and  early  condition  in  every  case  of  acute  osteomjelitis.  The 
oedema  of  the  soft  parts  is  caused,  in  part  at  least,  by  the  deep-seated 
venous  obstruction.  The  external  swelling  seldom  appears  before  the 
end  of  the  first  week,  but  when  it  once  shows  itself  it  increases  very 
rapidly.  The  secondary  suppurative  periostitis  results  in  extensive 
denudation  of  the  bone  of  this  membrane,  a  large  portion  of  the  shaft 
being  surrounded  by  pus.  As  soon  as  the  suppurative  inflammation 
extends  to  the  soft  tissues,  dilT'ase  burrowing  of  pus  takes  place  between 
the  bone  and  the  periosteum  and  among  the  muscles.  Within  a  few 
days  an  immense  abscess,  or  a  very  extensive  purulent  infiltration, 
develops  in  this  manner. 

Redness. — The  skin  over  the  aflTected  bone  presents  a  pale,  normal 
appearance  until  the  pus  reaches  the  subcutaneous  tissue,  when  it  presents 
a  red  or  brownish-red  discoloration.  The  superficial  veins  are  always 
dilated  and  turgid, — a  reliable  indication  of  the  existence  of  a  deep-seated 
thrombo-phlebitis. 

Synovitis. — Inflammation  of  joints  situated  in  close  proximit}-  to 
osteomyelitic  foci  is  the  rule.  Catarrhal  synovitis  appears  during  the 
first  few  weeks,  while  suppurative  synovitis  usually  occurs  later  as  a 
complication  of  acute  suppurative  osteomj^elitis.  If  the  effusion  into 
the  joint  is  of  a  serous  character,  it  occurs  not  as  a  result  of  infection 
with  pus-microbes,  but  in  consequence  of  vascular  distui-bances  outside 
the  limits  of  the  area  of  infection.  The  serous  effusion  appears  rapidly, 
gives  rise  to  pain  and  contraction  of  the  joint,  but,  as  a  rule,  disappears 
spontaneously  after  the  evacuation  of  pus.  Suppurative  synovitis 
follows  infection  of  a  joint  with  the  same  microbes  that  caused  the 
osteomyelitis,  which  reach  the  joint  either  directly,  through  some  patho- 
logical defect  of  the  epiphysis,  or  through  the  lymphatics  or  blood- 
vessels. The  occurrence  of  an  attack  of  suppurative  sjniovitis  greatly 
aggravates  the  general  symptoms,  and  is  attended  b}^  more  serious  local 
disturbances  than  is  the  case  if  the  eff"usion  is  of  a  non-septic  character. 
If  any  doubt  exist  in  reference  to  the  character  of  the  efl"usion  an 
exploratory  puncture  will  furnish  the  necessary  information. 


«. 


DIAGNOSIS.  239 

Epiphyseolysis.' — Separation  of  an  epiphj-sis  from  the  diaphysis  in 
the  epipb3-seal  line  is  not  an  infrequent  accident  in  cases  of  osteomyelitis 
of  the  long  bones.  It  is  a  pathological  fracture  which  occurs  in  conse- 
quence of  necrosis,  inflammator}'  osteoporosis,  or  molecular  disintegra- 
tion of  bone  in  the  epiphyseal  line.  It  is  readily  recognized  b}^  the 
existence  of  a  false  point  of  motion  and  the  displacements  which  usually 
attend  fractures  in  such  a  localit}^  Epiphyseol3'sis  seldom  occurs  before 
the  end  of  the  fourth  or  sixtli  week  from  the  beginning  of  the  attack. 

Loss  of  Function. — In  a  limb  the  seat  of  an  acute  osteomyelitis  all 
functions  are  usuall}'  completely  suspended.  It  is  as  useless  as  though 
one  of  the  principal  bones  had  been  fractured.  The  patient  is  unable  to 
raise  it,  or  to  move  the  nearest  joint.  The  limb  is  not  onl}-  useless,  but 
the  patient  complains  of  a  sensation  as  though  it  would  break  on  its 
being  lifted  or  otherwise  manipulated. 

DIAGNOSIS. 
Mr.  Holmes  has  well  said  that  acute  suppurative  osteomyelitis  is 
more  frequently  recognized  at  post-mortem  examinations  than  at  the 
bedside  of  the  sick.  It  has  often  been  mistaken  and  treated  for  other 
affections,  as  periostitis,  ostitis,  inflammation  of  joints,  rheumatism, 
typhoid  fever,  erysipelas,  and  even  phlegmonous  inflammation  of  the 
soft  parts.  When  we  remember  that  periostitis,  ostitis,  synovitis,  and 
cellulitis  are  secondary  lesions,  intimately  associated  in  the  clinical 
history  of  every  case  of  osteomyelitis,  and,  furthermore,  that  the  fever 
attending  it  closely  resembles  tj'phoid  fever,  it  is  not  surprising  that 
mistakes  in  the  early  diagnosis  of  this  disease  are  not  infrequent,  even 
in  the  practice  of  experienced  surgeons.  A  careful  consideration  of 
everj'  feature  of  the  clinical  picture  presented  b}^  each  case  can  only 
enable  us  to  arrive  at  correct  diagnostic  conclusions.  There  is  no  single 
pathognomonic  sj^mptom  that  would  infallibly  lead  us  to  a  correct  diag- 
nosis. The  presence  of  fat-globules  in  the  pus  was  regarded  as  diagnostic 
by  Chassaignac  and  Roser.  Fat-globules  are  often  found  in  osteo- 
myelitic  pus,  but  the}'  are  not  invariably  present,  and  may  also  occur  in 
the  pus  of  a  phlegmonous  inflammation.  An  important  element  in  differ- 
ential diagnosis  is  the  absence  of  external  swelling  for  the  first  few  days, 
regardless  of  the  severity  of  other  symptoms ;  also,  its  rapid  diffusion 
after  it  has  once  made  its  appearance.  In  periostitis  and  phlegmonous 
inflammation  of  the  connective  tissue,  swelling  is  one  of  the  earliest 
S3^mptoms.  In  osteomyelitis  the  superficial  swelling  is  at  first  oedema- 
tous,  extends  S3-mmetrically  around  the  entire  bone,  and  gradually 
diminishes  at  a  point  where  the  morbid  process  in  the  interior  of  the 
bone  has  become  arrested.     In  acute  cases,  fluctuation  appears  about  the 


240  PRINCIPLES   OF   SURGERY. 

end  of  the  first  or  during  the  second  week.  A  consecutive  inflammation 
of  proximal  joints  usually  makes  its  aj)i)earance  al)out  from  the  end  of 
the  first  to  the  fourth  week.  The  time  of  its  ai)pearance,  as  well  as  its 
character,  is  determined  l)y  the  causes  which  i)roduce  the  synovitis. 
While  joint  affections  are  almost  constant  in  osteomyelitis,  they  are 
seldom  associated  with  periostitis,  or  plastic  osteomyelitis.  The  char- 
acter of  the  fever  which  accompanies  grave  attacks  of  osteom^^elitis 
sometimes  obscures  the  local  symptoms  to  such  :in  extent  as  to  lead  the 
attendant  to  the  belief  that  the  patient  is  suffering  from  an  attack  of 
typhoid  fever.  Goltdammer  has  reported  a  typical  case  of  this  kind. 
The  general  symptoms  simulated  typhoid  fever  so  closely  that  the 
patient,  after  an  illness  of  ten  da3's,  was  sent  to  the  medical  wards  as  a 
severe  case  of  typhoid  fever.  The  pulse  ranged  between  110  and  120; 
temperature,  40°  to  41°  C.  Tympanites,  dry  tongue,  enlargement  of 
spleen,  bronchitis,  rapid  respiration,  and  delirium.  On  close  examina- 
tion, a  slight  swelling  was  found  over  the  lower  part  of  the  right  tibia, 
with  tenderness  on  pressure, — symptoms  which  finally  enabled  the  attend- 
ing physician  to  make  a  correct  diagnosis.  During  the  progress  of  the 
case,  pleuritis,  parotitis  duplex,  and  synovitis  of  the  right  shoulder-joint 
made  their  appearance.  The  patient  died  eight  days  after  admission,  or 
eighteen  days  from  the  beginning  of  the  disease.  The  necropsy  revealed 
the  existence  of  acute  osteomyelitis  of  the  tibia  and  pyaemia.  Many 
such  cases  have  been  recorded  where  the  differential  diagnosis  between 
acute  osteomyelitis  and  tj'phoid  fever  was  difficult,  if  not  impossible, 
until  the  local  sj'mptoms  became  more  prominent.  The  premonitory 
sj'mptoms  in  tj^phoid  fever  are  moi'e  constant  and  prominent  than  in 
osteomyelitis.  In  the  latter  affection  the  bronchial  or  intestinal  catarrh 
which  occasionally  precedes  the  attack  constitutes  the  only  premonitory 
s3'mptoms  which  have  been  observed,  and,  as  a  rule,  the  disease  com- 
mences abruptly  without  any  such  warnings.  Chassaignac  believes  that 
diarrhoea  is  present  in  almost  all  cases  in  the  beginning,  but  it  is  a  more 
constant  symptom  after  septicaemia  or  P3'aemia  have  made  their  appear- 
ance. The  temperature,  as  a  rule,  shows  less  variation  in  osteom3^elitis 
tlian  in  t3'phoid  fever.  After  the  initial  chill  and  the  usual  S3'mptoms 
attending  the  subsequent  fever,  the  first  symptom  that  points  to  osteo- 
m3-elitis  is  pain.  This  is  generall3"  severe,  deep-seated,  constant,  boring, 
tearing,  or  throbbing  in  character,  and  referred  to  the  primar3'  focus  of 
the  disease,  usually  in  the  vicinity  of  the  epiph3'seal  line.  Patients  old 
enough  to  describe  their  sensations  complain  of  a  feeling  as  if  the  bone 
Avas  being  broken.  They  object  to  moving  or  handling  of  the  limb  on 
account  of  fear  of  an  aggravation  of  this  distressing  sensation.  E.  von 
Wahl  makes  the  statement  that  fluctuation  is  at  first  circumscribed  in 


PROGNOSIS.  241 

phlegmonous  inflammation  of  the  connective  tissue,  while  it  is  diffuse 
from  the  beginning  in  osteomjelitis.  This  distinction  is  a  good  one. 
The  importance  of  searching  for  points  of  tenderness  in  the  diagnosis 
and  location  of  the  disease  has  already  been  alluded  to.  The  differential 
diagnosis  ])et\veen  rheiimatisn!,  gonorrhceal  arthritis,  and  osteomyelitis  is 
not  difficult,  as  in  the  former  diseases  the  joint  affections  occur  as  a 
primary  disease,  while  in  osteomyelitis  they  appear  as  complications. 

PROGNOSIS. 

Modern  aggressive  surgery  has  greatl}-  diminished  the  mortalit}^  of 
acute  osteomyelitis.  Under  the  old,  expectant,  non-antiseptic  treatment 
it  was  great.  Thus,  Demme  lost  4  out  of  17  cases;  Luecke,  11  out  of 
24 ;  Kocher,  9  out  of  26  ;  and  Schede,  3  out  of  23  cases.  Multiple  osteomye- 
litis, with  grave  sj^mptoms  of  septicaemia  from  the  beginning,  almost  with- 
out exception  proves  fatal  in  less  than  two  weeks.  Death  in  such  cases  is 
caused  b}-  progressive  sepsis  resulting  from  the  entrance  of  large  quan- 
tities of  pus-microbes  into  the  circulation.  After  death  no  character- 
istic macroscopical  lesions  can  be  found  in  distant  organs,  and  micro- 
scopical examination  reveals  onl}'  the  minute  changes  in  the  capillary 
vessels  typical  of  acute  septicaemia.  If  the  patient  escape  this,  the  first 
source  of  danger  to  life,  he  is  still  exposed  during  the  duration  of  the 
acute  symptoms  to  the  more  remote  risks  incident  to  the  presence  of 
septic  thrombo-phlebitis.  If  any  of  the  thrombi  undergo  softening  and 
disintegration,  fragments  reach  the  general  circulation  and  constitute 
infected  emboli,  which  establish  in  distant  organs,  notably  the  lungs  and 
kidneys,  independent  centres  of  suppuration, — the  so-called  metastatic  or 
pytemic  abscesses.  The  accession  of  this  fatal  complication  is  announced 
by  recurring  chills,  an  intermittent  form  of  fever,  and  is  followed  within 
a  short  time  b}-  death  from  sepsis  or  exhaustion.  Another  fatal  accident 
which  maj"  occur  is  fat-embolism.  The  medullar}-  tissue  is  liquefied  by 
the  suppurative  inflammation,  and  some  of  the  free  fat-globules  may  be 
forced  into  the  circulation  b}'  the  intra-osseous  pressure,  and  death  is 
preceded  b}-  rapid,  shallow  breathing;  cyanosis;  small,  rapid  pulse, — 
S3'mptoms  which  point  to  the  existence  of  an  obstruction  to  the  passage 
of  the  blood  from  the  right  to  the  left  side  of  the  heart.  Extensive 
destruction  of  the  medullar}^  tissue  is  always  followed  by  marked 
anaemia,  and  this  condition  is  a  prominent  sj-mptom  in  all  cases  of  osteo- 
m3-elitis,  as  tliis  disease  seriously  impairs  the  function  of  one  of  the 
important  l)lood-producing  organs.  Schede  has  seen,  in  cases  of  acute 
osteomyelitis,  tlie  })roportion  of  the  white  to  tlie  red  blood-corpuscles 
increased  to  1:100.  The  clinical  thermometer  is  an  important  prognostic 
aid   in  this  as  well  as  in  many  other  acute  infective  processes.     If  the 

16 


242  PRINCIPLES   OF   SURGERY. 

morning  and  evening  temperature  remain  continuously  high, — that  is  to 
sa^',  ranges  between  40°  to  40.5°  C.  during  tlie  first  week, — it  indicates  a 
severe  case.  The  more  the  general  symptoms  resemble  a  severe  case  of 
typhoid  fever,  the  graver  tlie  prognosis.  The  occurrence  of  decubitus  is 
always  an  unfavorable  sign.  In  regard  to  the  function  of  the  limb  after 
an  attack  of  acute  osteomyelitis,  a  few  words  are  necessary.  Necrosis 
of  the  bone  to  a  greater  or  less  extent  is  the  rule.  The  extent  of  perios- 
teal detachment  during  the  acute  stage  is  no  indication  of  the  area  of 
subsequent  sequestration,  as  the  greater  part  of  the  denuded  bone  ma^' 
receive  an  adequate  blood-supply  from  the  vessels  within  the  bone,  and 
soon  becomes  covered  with  granulations,  and  later  unites  with  the  peri- 
osteum or  the  paraperiosteal  tissues.  Joint  affections  and  partial  or 
complete  separation  of  one  or  more  epiphyses  are  frequent  complica- 
tions. A  catarrhal  effusion  is  generally  removed  b^'  absorption,  after 
the  subsidence  of  the  acute  sjnnptoms,  and  the  functions  of  the  joints 
are  restored  completely.  If  the  effusion  is  sei*o-purulent  and  the  articu- 
lar cartilages  remain  intact,  aspiration,  with  subsequent  washing  out  of 
the  joint  with  an  antiseptic  solution,  may  be  sufficient  to  remove  the 
effusion  and  restore  the  usefulness  of  the  limb.  Stiffness  of  the  joint 
and  malposition  of  the  articular  surfaces  of  the  bones  are  events  that 
cannot  be  avoided  in  all  cases,  even  by  the  most  skillful  and  attentive 
treatment.  If  the  articular  cartilages  are  destroyed  by  suppurative 
arthritis,  the  best  result  that  can  be  hoped  for  is  a  useful  but  ankylosed 
joint.  Pathological  fractures  through  the  sliaft  of  a  bone  or  epiphj'seo- 
lysis  are  complications  which  greatly  tax  the  duties  of  the  attending 
surgeon,  but  from  which  the  patients  frequentl}^  recover  with  a  useful 
limb. 

PATHOLOGICAL     ANATOMY. 

Acute  osteomyelitis  is  essentiall}^  a  phlegmonous  inflammation  of 
the  marrow  of  bone.  This  disease  attacks,  preferably,  the  long  bones, 
although  the  scapula,  clavicle,  ribs,  and  ilium  are  also  frequently  affected, 
especially  in  cases  of  multiple  osteomyelitis.  Of  the  long  bones  the 
femur  is  most  frequentl3^  affected.  Seventy-three  per  cent,  of  all  of 
Demme's  cases  involved  this  bone.  In  the  femur  the  disease  manifests 
a  special  predilection  for  the  lower  epiphyseal  region,  while  in  the  tibia 
the  order  of  frequency  is  reversed.  The  great  frequency  with  which 
the  extremities  of  the  shaft  of  the  long  bones  are  affected  receives  a 
plausible  explanation  from  the  activity  of  the  physiological  changes 
during  the  growth  of  bone,  and  perhaps  to  a  lesser  extent  b}'  the  greater 
frequency  of  traumatism  in  these  localities.  Englisch  claimed  that  the 
extremity  of  the  shaft  and  epiphysis,  toward  which  the  nutrient  artery 
is  directed,  is  alwa^'s  primarily  alTected,  on  account  of  the  greater  blood- 


PATHOLOGICAL    ANATOMY.  243 

pressure  in  that  locality.  Clinical  experience  lias  proved  the  contrar}-. 
As  acute  osteom^-elitis,  without  direct  exposure  of  the  marrow,  is  caused 
1)3'  infection  with  pus-microbes,  which  reach  the  tissue  through  the 
circulation,  the  inflammatory  process  must  commence  in  the  capillaries 
from  mural  implantation  of  microbes  or  leucocytes  containing  them. 

The  cause  of  the  inflammation  is  primarily'  endo-A-ascular,  and 
reaches  the  medullary  tissue  with  the  leucoc3-tes.  Intense  alteration  of 
the  capillary  wall  is  always  present  in  these  cases,  giving  rise  to  rhexis. 
Pus  from  acute  osteomj-elitis  almost  alwa3's  presents  a  reddish  appear- 
ance, which  is  owing  to  the  presence  of  extravasated  blood.  The  inflam- 
mation extends  rapidl3'  to  the  larger  veins,  which  become  blocked  b3-  the 
formation  of  a  thrombus.  If  pus-microbes  enter  the  thrombosed  veins 
in  sufficient  quantit3^  to  cause  liquefaction  of  the  coagulated  blood, 
pyaemia  results  from  transportation  of  fragments  of  such  infected 
thrombi  to  the  distant  circulation.  Extensive  thrombo-phlebitis  results 
in  arrest  of  circulation  in  portions  of  the  bone,  or  perhaps  of  the  entire 
shaft,  which  is  followed  b3'  the  usual  consequences  of  such  a  condition — 
necrosis.  Xecrosis  is  undoubtedl3'  also  caused  b3-  the  local  toxic  effect 
of  the  ptomaines  of  the  pus-microbes  upon  the  tissues  and  the  pressure 
resulting  from  the  presence  of  the  inflamniator3'  exudate  in  a  tissue  not 
capable  of  distention.  The  central  medullar3'  cavit3'  is  rapidh*  trans- 
formed into  an  abscess-cavit3'.  The  pus  occupies  either  the  entire 
cavit3',  a  certain  section  of  it,  or  in  the  form  of  multiple  circumscribed 
abscesses  or  infiltration.  The  infection  from  the  central  focus  extends 
along  the  blood-vessels  and  soon  reaches  the  periosteum,  which  becomes 
the  seat  of  an  inflammation  which  resembles,  pathologicall3',  the  medul- 
lar3'  lesion  in  ever3-  respect  primar3^  The  secondar3'  periostitis  in  ever3' 
case  of  acute  osteomyelitis  alwa3's  assumes  a  suppurative  t3'pe.  Pus 
accumulates  between  the  periosteum  and  bone,  causing  often  extensive 
denudation  of  the  bone.  The  periosteum  at  some  points  is  destro3'ed 
when  the  pus  reaches  the  surrounding  connective  tissue,  which  then 
becomes  the  seat  of  a  phlegmonous  inflammation.  The  periosteal  defects 
are  not  restored  subsequentl3',  and  at  these  points  openings  remain  later 
in  the  new  bone,  called  cloacae.  After  the  active  S3'mptoms  have  sub- 
sided the  suppurative  periostitis  gives  wa3^  to  a  process  of  repair,  during 
which  the  periosteum  forms  a  case  of  new  bone  arouud  the  necrosed 
portion,  which,  in  technical  language  is  called  an  involuo'um.  The 
abscess  in  the  soft  parts  heals,  and  one  or  more  fistulous  communica- 
tions between  the  surface  of  the  skin  and  the  dead  bone  in  the  interior 
of  the  involucrum  remain.  The  external  openings  are  often  quite  distant 
from  the  cloacae,  and  in  such  cases  it  is  difficult,  if  not  impossible,  to 
discover  the  dead   bone   b3'   probing.     The  necrosed   bone   is  called   a 


24:4:  PRINCIPLES   OF   SURGERY. 

sequestrum.  If  necrosis  has  occurred  :it  diflVront  points  several  sequestra 
will  be  included  by  the  involucruni.  Separation  of  a  sequestrum,  like 
the  elimination  of  necrosed  soft  tissues,  is  accomplished  either  b}-  suppu- 
ration or,  what  is  more  common,  by  granulation.  Such  pieces  of  bone 
always  show  an  irregular  or  deutated  outline,  which  is  due  either  to  the 
original  shape  of  the  sequestrum  or  to  the  action  of  tlie  granulations, 
v,liieh  diminish  the  size  of  the  detached  bone  after  its  separation, 
Necrosis  is  said  to  be  central  if  the  sequestrum  is  composed  of  tissue 
■rom  the  interior  of  the  Ijone,  complete  if  it  represent  the  entire  thick- 
r.e^s  of  the  bone,  and  cortical  if  it  is  composed  of  the  external  compact 
layer  only.  In  complete  necrosis  a  pathological  fracture  necessarily 
takes  place  if  separation  occur  before  a  firm  involucrum  has  formed. 
In  such  cases  restoration  of  the  continuity  of  the  bone  is  effected  by  the 
new  bone.  In  central  necrosis  the  dead  bone  is  always  encased  in  an 
iiivolucrum.  In  cortical  necrosis  spontaneous  elimination  of  the  seques- 
tnnn  frequently  occurs  if  the  bone  separate  before  an  involucrum  forms 
around  it,  or,  if  an  involucrum  does  not  form,  on  account  of  destruction 
of  a  corresponding  portion  of  the  periosteum. 

The  medullary  canal  in  the  new  bone,  after  central  or  total  necrosis, 
is  seldom  restored  to  perfection.  The  new  bone  is  harder  and  heavier 
than  normal  bone  (osteosclerosis),  but  in  exceptional  cases  it  remains 
porous  and  soft  (osteoporosis), — a  condition  described  by  Yolkmann  and 
Schede,  which  ma}'  become  the  cause  of  various  degrees  of  deformity, 
from  bending  of  the  shaft.  Separation  of  a  sequestrum  will  take  place 
in  from  four  weeks  to  three  months,  according  to  the  age  of  the  patient 
and  the  location  and  extent  of  the  necrosis. 

TREATMENT. 

An  early  and  correct  diagnosis  is  of  the  greatest  importance  in  the 
treatment  of  acute  osteomyelitis.  As  the  gastro-intestinal  canal  is 
undoubtedl}'  more  frequentl}'  the  route  through  wdiich  infection  takes 
place  than  is  generall}'  supposed,  and  as  nature's  resources  often  attemp/t 
elimination  of  the  pathogenic  micro-organisms  in  this  direction,  it  would 
appear  rational  to  administer  a  brisk  cathartic  soon  after  the  appearance 
of  the  first  symptoms,  as  such  treatment  might  prove  of  great  value  in 
arresting  further  infection  from  this  source.  A  large  dose  of  calomel, 
administered  for  the  same  purpose  and  in  the  same  manner  as  advised 
during  the  early  stage  of  typhoid  fever,  could  not  fail  to  produce  a  salu- 
tary effect.  Kocher  has  advised  the  internal  use  of  salicylate  of  soda, 
giving  from  6  to  24  grammes  in  divided  doses  during  twenty-four  hours. 
In  such  doses  this  remedy  would  also  have  some  effect  in  reducing  the 
temperature,  which  is  constantly  high  in  all  acute  cases.     Opium  must 


TREATMENT.  245 

be  given  in  sufficient  doses  to  alleviate  pain.  The  affected  limb  should 
be  placed  in  a  slightly -elevated  position. 

Demme,  Billroth,  and  Yolkmann  recommend  vesication  by  frequently- 
repeated  applications  of  the  strong  tincture  of  iodine.  It  is  doubtful  if 
such  treatment  has  an}'  influence  in  arresting  or  even  retarding  the 
further  development  of  the  disease.  The  use  of  the  ice-bag  is  rational, 
and  often  relieves  pain.  In  multiple  osteom^-elitis,  with  pronounced 
symptoms  of  progressive  sepsis  almost  from  the  beginning  of  the  attack, 
it  is  doubtful  whether  an}-  surgical  treatment  will  have  an}-  effect  in 
pi-eventing  a  fatal  termination.  In  such  cases  general  infection  occurs 
almost  from  the  very  beginning,  and  at  the  necrops}-  verj'  little,  if  an}-, 
pus  is  found  in  the  inflamed  medullary  tissue.  The  indicatio  vitalis  in 
these  cases  calls  for  the  use  of  stimulants. 

In  regard  to  the  propriety  of  making  early  incisions,  the  greatest 
diversity  of  opinion  has  prevailed  in  the  past.  Previous  to  the  researches 
of  Demnie,  early  and  free  incisions  were  practiced  very  generally.  As 
the  results  following  the  treatment  were  frequently  disastrous,  Demme 
was  led  to  adopt  a  more  conservative  treatment.  He  advised  an  expec- 
tant plan  to  be  pursued  until  the  disease  should  exhaust  itself,  as  it  were, 
as  indicated  by  reduction  of  temperature  and  cessation  of  the  active 
symptoms  of  the  inflammation,  and  then  he  argued  the  propriety  of 
making  large  incisions.  For  the  purpose  of  affording  an  outlet  for  the 
pus,  Klose  made  early  and  small  incisions  at  the  junction  of  the  epiphysis 
with  the  diaphysis.  Oilier  advocntes  early  incision,  combined  with 
trephining  of  the  bone.  In  a  communication,  read  before  the  Academy 
of  Paris,  he  claims  that  trephining  is  applicable  to  all  forms  of  osteo- 
myelitis with  severe  general  symptoms.  He  maintains  that  trephining, 
even  in  the  most  diffuse  form,  will  arrest  the  intense  pain  by  relieving 
pressure;  and  where  the  disease  is  circumscribed  it  affords  prompt  and 
decided  relief  In  the  acute  form,  he  claims,  trephining  will  often  pre- 
vent external  necrosis  and  fatal  symptoms,  while  in  the  subacute  and 
chronic  forms  it  removes  the  most  distressing  symptom — pain.  In  8  out 
of  19  cases  of  early  trephining  he  found  pus  ;  and  in  10  cases  the  marrow 
presented  different,  diverse,  morbid  appearances;  v.liile  in  the  last  case, 
a  case  of  acute  osteomyelitis  of  the  femur,  a  large  quantity  of  fluid  blood 
escaped.     Two  of  the  19  cases  died  of  pyaemia. 

Since  osteomyelitis  has  been  recognized  as  a  microbic  disease  at- 
tempts have  been  made  to  arrest  the  disease  by  intraosseous  injections 
of  germicidal  solutions.  Hueter  has  employed  parenchymatous  injections 
of  solutions  of  carbolic  acid  with  decided  benefit  in  the  treatment  of 
other  inflammatory  affections  of  bones  and  soft  tissues.  Kocher  recom- 
mended that  the  soft  tissues  around  the  infected  bone  should  be  disin- 


246  PRINCIPLES   OF    SUUGEKY. 

fected  b}'  saturating  them  with  a  solution  of  carbolic  acid,  thrown  in 
with  an  ordinary  hypodermic  syringe.  Later,  the  same  autlior  suggested 
the  propriety  of  making  intra-osseous  injections  after  penetrating  the 
bone  witli  a  small  perforation  and  injecting  carbolized  water,  thus  reach- 
ing the  primary  focus  of  the  disease.  Theoretically,  the  suggestion 
appears  valuable;  practically,  intra-osseous  injections  in  the  treatment 
of  acute  suppurative  osteomyelitis  have  proved  a  foilure.  If  it  is  next 
to  impossible  to  al)ort  even  a  small  circumscribed  suppurative  inflamma- 
tion in  the  soft  tissues  with  antiseptic  parenchymatous  injections,  it  is 
not  surprising  to  learn  that  the  same  treatment  has  invariably  failed  in 
arresting  suppuration  in  the  interior  of  bones.  Intra-osseous  injections 
are  no  longer  used  in  the  treatment  of  acute  suppurative  osteomyelitis. 

Antiseptic  surgery  has  revolutionized  the  treatment  of  acute  suppu- 
rative osteomyelitis.  The  diseased  medulla  is  now  attacked  with  the 
same  impunity  as  the  soft  tissues  outside  of  the  bones.  The  objections 
to  large  incisions  increasing  the  danger  from  sepsis  and  pyaemia  are  no 
longer  well-founded,  as  incisions  made  under  antiseptic  precautions  for 
the  evacuation  of  pus,  instead  of  increasing  the  risks  of  death  from  sepsis 
or  pyfpmia,  are  now  considered  the  best  means  to  prevent  these  fatal 
complications. 

It  can  now  be  laid  down  as  an  axiom  in  surgery  that  the  medullary 
cavity,  in  every  case  of  acute  suppurative  osteomyelitis,  should  be  freely 
exposed  and  submitted  to  direct  and  most  thorough  antiseptic  treatment 
as  soon  as  a  positive  diagnosis  can  he  made.  It  would  be  a  serious  and 
unjustifiable  mistake  to  open  a  health}^  medullar}^  cavity;  but,  on  the 
other  hand,  it  would  also  be  next  to  criminal  negligence  to  wait  for 
fluctuation  before  resorting  to  operative  treatment  in  a  case  of  acute 
osteomyelitis.  The  bone  should  be  opened,  the  infected  medulla  removed, 
and  the  cavity  disinfected  before  suppuration  has  extended  to  the  peri- 
osteum and  the  surrounding  soft  tissues.  The  intelligence  and  moral 
courage  of  a  surgeon  can  be  nowhere  better  tested  and  gauged  than 
when  he  is  confronted  by  a  recent  case  of  acute  osteom3'elitis.  He 
must  be  sure  of  his  diagnosis,  and  this  often  requires  no  ordinar}' 
erudition  and  diagnostic  skill.  A  positive  diagnosis  made,  he  must 
possess  enough  courage  to  face  the  popular  prejudice  against  early 
operation  under  circumstances  where  success  is  not  alwa3^s  attainable. 
Impressed  with  the  imperative  necessitj^  of  operative  interference  from 
his  knowledge  of  a  case,  a  conscientious  surgeon  will  not  flinch  from  his 
duty,  even  under  the  most  unpromising  circumstances.  If  the  respon- 
sibilities and  risks  are  great,  he  will  do  well  to  fortify  his  course  by 
calling  into  consultation  one  or  more  of  his  colleagues,  to  protect  himself 
against  unmerited  criticism  in  the  future,  or,  perchance,  a  suit  for  mal- 


TREATMENT.  247 

practice.  An  earl}'  radical  operation  for  osteomyelitis  (and  the  author 
means  by  this  an  operation  done  as  soon  as  a  positive  diagnosis  can  be 
made,  and  before  any  external  swelling  has  appeared)  accomplishes  the 
following  most  desirable  results  :  1.  It  removes  pain.  2.  It  enables  the 
surgeon  to  remove  the  local  cause  of  the  disease  completel}^  or  in  part. 
3.  It  prevents  extensive  necrosis.  4.  It  is  the  best  proph3'lactic  measure 
against  fatal  septicaemia  and  p3ajmia.  5.  It  prevents  extensive  destruc- 
tion of  the  periosteum  and  other  contiguous  soft  parts.  6.  It  cuts  short 
the  attack  and  expedites  recovery. 

As  we  have  seen,  the  pain  which  attends  osteom3'elitis  is  caused  by 
the  intra-osseous  tension  and  by  the  secondary  periostitis.  If  the 
medullar}'  cavity  is  opened  freely  before  suppurative  periostitis  has 
developed,  the  operation  removes  the  conditions  which  cause  the  pain, 
and  will  therefore  accomplish  at  once  what  anodynes  and  external  appli- 
cations can  do  but  imperfecth".  The  removal  of  the  infected  tissues 
fulfills  the  etiological  indications  of  the  disease,  the  removal  of  the  pus- 
microbes  completely-  or  in  part,  which,  with  thorough  disinfection  of  the 
cavity,  prevents  the  further  extension  of  the  disease.  Necrosis  takes 
place  from  the  action  of  the  pus-microbes  and  their  ptomaines  on  the 
tissues,  intrn-osseous  tension,  and  vascular  obstruction,  all  of  which 
causes  are  either  removed  or,  at  least,  favorably  modified  b}'  an  early 
radical  operation.  Limitation  of  necrosis  is  one  of  the  most  marked 
results  of  all  early  antiseptic  operations  for  acute  osteom^^elitis.  Progres- 
sive sepsis  is  caused  In'  the  introduction  of  pus-microbes  and  their 
ptomaines  from  the  osteomyelitic  focus  into  the  general  circulation  ; 
hence,  there  is  no  better  way  in  which  this  fatal  complication  can  be  pre- 
vented than  by  the  removal  of  the  infected  tissues  and  subsequent 
disinfection  of  the  cavity,  followed  b}-  efficient  drainage  and  strict  anti- 
septic treatment  of  the  wound.  As  pyaemia  is  always  caused  by  septic 
thrombo-phlebitis,  no  surer  way  of  guarding  against  it  could  be  devised 
than  the  early  removal  of  the  infected  tissues,  which  maj-  include  the 
vessels  with  a  beginning  thrombo-phlebitis.  If  the  interior  of  an  osteo- 
myelitic bone  is  rendered  accessible  to  direct  means  of  disinfection,  such 
treatment  will  often,  if  not  invariabl}',  prevent  the  extension  of  the  sup- 
purative inflammation  to  the  periosteum  and  surrounding  connective 
tissue,  which  constantly  occurs  when  the  patients  are  treated  upon  the 
expectant  plan.  An  early  radical  operation,  b}'  limiting  the  necrosis  and 
extension  of  the  inflammation  to  the  surrounding  soft  tissues,  shortens 
the  attack,  and  is  conducive  toward  establishing  at  an  earlj'time  a  repar- 
ative process  in  place  of  one  of  destruction.  Pathological  fractures  will 
become  less  frequent  complications  in  acute  osteomyelitis  as  soon  as 
earl}'  radical  operations  are  more  generally  adopted.     Earl}'  operations 


248  PRINCIPLKS   OF    SURGERY. 

under  antiseptic  precautions,  in  short,  are  life-saving  operations  ;  at  the 
same  time,  thoy  will  leave  the  parts  in  a  more  satisfactory-  condition  for 
ra[)id  and  satisfactory  repair.  An  earl)'  operation  I  should  call  one  done 
l)efore  secondary  suppurative  periostitis  has  aj)peared.  An  intermediate 
operation  for  acute  osteom3elitis  is  one  performed  after  suppuration  has 
occurred  around  the  bone  first  affected,  and  late  operations  are  under- 
taken for  the  removal  of  necrosed  bone. 

Early  Operations. — The  surface  of  the  limb  is  prepared  in  the  same 
manner  as  for  other  antiseptic  operations.  The  primary  focus  of  the 
disease,  usually  in  the  vicinity  of  an  epiphyseal  line,  is  accurately  located 
by  searching  for  the  most  tender  point.  Over  this  point,  or  as  near  to 
it  as  the  nature  of  the  soft  parts  will  permit,  an  incision  is  made  down 
to  the  bone.  As  the  operation  is  to  be  done  below  Esmarch's  constrictor, 
the  soft  tissues  can  be  carefully  examined  during  every  step  of  the 
operation,  and  their  exact  condition  ascertained.  The  skin  and  under- 
lying fascia  are  cut  through  with  one  stroke  of  the  knife,  when  the  knife 
should  be  laid  aside  and  the  remaining  tissues,  down  to  the  bone,  are 
carefully  separated  with  the  finger,  which  can  be  readil}^  done  by  follow- 
ing the  intermuscular  sei)ta.  The  periosteum,  even  at  an  earl}'  stage, 
will  be  found  vascular  and  easily  separated  from  the  bone.  This 
structure  is  then  reflected  with  the  soft  tissues  on  each  side,  and  held 
out  of  the  way  with  retractors.  The  bone  is  then  opened  with  a  small, 
round  chisel.  The  trephine  should  never  be  used,  as  it  is,  to  say  the 
least,  a  bungling  and  inefflcient  instrument,  while  the  chisel  is  an  instru- 
ment of  precision.  For  the  first  or  exploratory  opening  a  semicircular 
chisel  should  be  used  ;  in  the  further  steps  of  the  operation  ordinary 
chisels,  such  as  are  used  b}^  carpenters,  answer  an  excellent  purpose. 
As  the  first  opening  will  probably  be  made  near  an  epiphyseal  extremity, 
at  a  point  where  the  compacta  is  verj'  thin,  the  chiseling  is  attended  by 
no  diflSculties.  The  opening  is  made  directly  toward  the  centre  of  the 
bone.  If  no  pus  has  formed  the  osteomyelitic  focus  is  recognized  b}'^ 
the  softness  and  great  vascularity  of  the  tissues  and  the  escape  of  bloody 
serum.  If  pus  is  found  it  will  probably  appear  at  this  time  as  an  infil- 
tration. The  object  of  the  operation  is  not  only  to  open  the  bone,  but 
to  remove  all  of  the  infected  tissues.  The  opening  in  the  bone  is,  there- 
fore, enlarged  in  the  direction  of  the  shaft  to  the  extent  of  the  disease 
in  its  interior.  If  the  suppurative  inflammation  is  extensive,  involving- 
half  of  the  bone,  or,  perhaps,  the  entire  shaft,  it  is  advisable  to  make 
several  incisions  over  the  bone  in  the  same  line  instead  of  one  large 
incision,  thus  avoiding  a  large  wound  and,  perhaps,  injur}^  of  important 
structures;  at  the  same  time  the  interior  of  the  bone  is  rendered  accessible 
to  direct  treatment  by  opening  the  bone  at  the  corresponding  points  and 


TREATMENT.  249 

scraping  out  the  medullaiy  tissue  contained  in  tlie  intervening  sections 
witli  a  sliarp  spoon,  tlie  handle  of  which  can  be  bent  at  an}^  desirable 
angle.  After  the  whole  cavity  has  been  thoroughly  curetted  it  is  dis- 
infected by  irrigating  it  with  a  solution  of  corrosive  sublimate  (1  to  1000), 
and  then  dried  and  mopiied  out  with  a  10-per-cent.  solution  of  chloride 
of  zinc.  Peroxide  of  hydrogen  is  also  an  excellent  remedy  for  disin- 
fecting the  bone-cavity  after  curetting.  The  cavity  is  then  packed  with 
iodoform  gauze,  which  is  brought  out  of  the  wouijd  or  wounds  to  serve 
the  purposes  of  a  capillary  drain.  A  copious  antiseptic  dressing  is 
applied,  and  the  limb  immobilized  in  proper  position  upon  a  splint.  A 
fall  in  the  temperature,  and  otlier  signs  of  improvement  soon  after  the 
operation,  are  indicative  tluit  the  desired  object,  primary  disinfection  of 
the  osteomyelitic  focus,  has  been  attained.  If  on  the  following  da}'  the 
temperature  shows  no  reduction,  the  dressings  are  removed,  antiseptic 
irrigations  are  again  employed,  and  the  limb  is  dressed  antiseptically. 
Should,  in  spite  of  the  early  operation  and  careful  antiseptic  after-treat- 
ment, the  suppurative  inflammation  extend  to  the  periosteum  and  the 
connective  tissue,  the  antiseptic  occlusive  dressing  should  give  way  to 
warm  compresses  kept  saturated  with  one  of  the  mild  antiseptic  solu- 
tions. Frequent  irrigations  Avith  a  2-per-ceiit.  boracic-acid  solution,  a  ^ 
to  1-per-cent.  solution  of  acetate  of  aluminum,  or  a  weak  aqueous  solu- 
tion of  tincture  of  iodine  should  be  made,  and  the  limb  confined  upon  a 
suspension  splint. 

Intermediate  Operations. — If  a  case  of  acute  osteomyelitis  come 
imder  treatment  after  purulent  infiltration  has  occurred  around  the 
affected  bone,  no  time  should  be  lost  in  evacuating  the  pus  by  incision 
and  drainage.  Multiple  incisions  and  numerous  tubular  drains  are  often 
required  to  effect  complete  evacuation  and  secure  free  drainage.  In 
these  cases  operations  on  the  bone  itself  should  be  limited  to  making 
smaller  openings  in  the  exposed  portion  of  the  bone,  for  the  purpose  of 
reaching  its  interior  with  antiseptic  irrigations.  Large  openings,  under 
these  circumstances,  might  lead  to  pathological  fractures.  The  subse- 
quent treatment  is  conducted  on  the  same  principles  as  a  case  of 
phlegmonous  inflammation  and  pundent  inflammation  of  the  soft  parts. 

As  in  the  early  treatment  of  osteomyelitis  by  radical  operation,  the 
limb  must  be  supported  in  a  desirable  position  by  some  kind  of  a  splint. 
The  use  of  a  i)ioper  splint  in  the  treatment  of  acute  osteomyelitis  is  in- 
dispensable. A  well-fitting  posterior  splint,  or  the  anterior  suspension 
splint  of  R.  N.  Smith,  secures  rest  for  the  limb,  i)revents  contractures 
and  sul)lux;iti(iu  of  joints,  and  finall}'  diminishes  the  frequency  of  patho- 
logical fractures.  Catarrhal  synovitis  is  treated  by  aspiration,  and  sup- 
purative synovitis  by  incision,  drainage,  and  antiseptic  irrigations.   During 


250  PRINCIPLES   OF    SURGERY. 

the  ncnU>  stngc  of  suppurative  osteomj^elitis  the  removal  of  an  entire 
shaft  of  a  long  bone  should  be  limited  to  one  bone  of  the  forearm  or  leg, 
as  the  removal  of  the  entire  shaft  of  the  humerus  or  femur  before  the 
formation  of  an  involucriim  of  suflicient  tirmness  to  act  as  an  efficient 
sup[)ort  would  greatly  complicate  the  mechanical  part  of  the  after-treat- 
ment, and  tlie  procedure  might  result  in  imperfect  restoration  of  the  bone 
removed.  Where  the  greater  portion  or  the  entire  shaft  of  a  bone  has 
become  necrosed  and  has  separated  at  one  or  botli  epiphyseal  junctions, 
it  m.'i}^  become  necessar}'  to  remove  it  during  the  acute  stage  to  avert 
death  from  exhaustion  from  profuse  discharges  and  septic  fever  inci- 
dent to  the  presence  of  such  a  large  septic  foreign  body.  It  has  been 
argued  against  such  a  procedure  that  the  bone  would  not  be  regenerated 
after  its  removal.  This  fear,  however,  is  not  supported  by  facts,  as  when 
the  periosteum  and  the  epiph3^sis  remain  a  good,  if  not  perfect,  substitute 
is  reproduced.  Duplay,  Holmes,  McDougal,  Lefort,  Giraldes,  Spence, 
Petrequin,  Wilms,  Cheever,  Ropes,  and  Gay  have  each  reported  cases 
where  almost  complete  reproduction  followed  the  removal  of  tlie  entire 
shaft.  It  is  very  important,  especially  in  children,  to  preserve  both 
epipli3-ses,  to  prevent  subsequent  shortening  and  other  deformities  of  the 
limb.  Where  the  continuity  of  a  bone  has  been  destroj'ed,  either  by  a 
pathological  fracture  or  the  removal  of  a  part  or  an  entire  diaphysis, 
which  has  separated  before  the  involucrum  has  become  sufficiently  firm 
to  serve  the  purpose  of  an  efficient  mechanical  support,  a  suitable  me- 
chanical support  must  be  applied  for  a  long  time  to  guard  against  short- 
ening and  bending  of  the  new  bone.  During  the  septic  stage  of  acute 
osteom3'elitis  with  suppurative  synovitis  amputation  ma}-  become  neces- 
sar}'  to  save  the  life  of  the  patient.  In  exceptional  cases  the  same  sad 
alternative  ma\'  become  a  necessity  after  the  acute  symptoms  have  sub- 
sided, for  the  purpose  of  removing  the  source  of  exhausting  suppurative 
discharges.  Our  present  means  of  treating  abscesses,  diffuse  purulent 
infiltrations,  and  suppurative  diseases  of  joints  are,  fortunately,  so  perfect 
and  efficient  that  even  severe  cases  can  be  treated  on  a  more  conservative 
plan,  and  amputation  should  be  restricted  to  extreme  cases  as  a  dernier 
ressort.  Should  signs  of  p3-8eraia  arise,  our  main  reliance  must  be  placed 
on  the  administration  of  large  doses  of  quinine  and  alcohol.  Luecke 
has  obtained  the  best  results  from  large  doses  of  alcoholic  stimulants. 
Instances  have  been  reported  where  two  pint-bottles  of  cognac  were 
given  during  twenty-four  hours  with  decided  benefit.  Osteom3'elitic 
patients  should  be  surrounded  b}'  the  most  favorable  hygienic  influ- 
ences, as  fresh  air,  equable  temperature,  light,  and  an  abundance  of  plain, 
nutritious  food.  As  soon  as  the  acute  symptoms  have  subsided,  iron, 
especially  tinctura  ferri  chloridi,   should    be   freely  administered.      If 


TREATMENT.  251 

osteomyelitis  is  complicated  by  the  co-existence  of  other  diseases,  siicli 
as  syphilis,  tuberculosis,  rachitis,  etc.,  the  treatment  of  the  latter  should 
receive  appro})riate  attention. 

Late  Operations. — As  late  operations  will  be  considered  the  operative 
removal  of  sequestra.  The  operation  for  the  removal  of  detached  dead 
bone  is  called  necrotomy  or  sequestrotomy.  The  operative  removal  of  a 
sequestrum  should  always  be  postponed  until  complete  separation  has 
taken  place  and  the  involucrum  is  strong  enough  to  furnish  the  neces- 
sary mechanical  support.  If  an  operation  is  undertaken  at  an  earlier 
time  there  is  danger  of  unnecessarily  removing  a  portion  of  health}-  bone 
or  of  leaving  a  part  of  the  sequestrum.  Necrosis  is  not  a  disease,  but 
always  a  result  of  a  destructive  inflammation.  It  is  not  always  easy  to 
determine  whether  separation  of  the  sequestrum  has  taken  place  in  a 
given  case.  The  sinus  leading  down  to  the  dead  bone  ma}'  be  so  tortu- 
ous that  it  is  impossible  to  introduce  a  probe  into  the  interior  of  the 
involucrum.  Again,  if  the  sequestrum  is  felt  with  the  probe  it  is  often 
impossible,  by  any  kind  of  manipulations,  to  ascertain  in  this  manner  its 
mobility,  as  it  is  often  firmly  encased  in  a  bed  of  granulations.  The  time 
required  in  separation  of  the  sequestrum  varies  greatly, — a  whole  pha- 
lanx of  a  finger  may  be  separated  completely  in  four  weeks,  a  cortical 
sequestrum  of  a  long  bone  may  become  detached  in  six  weeks  to  two 
months,  while  the  separation  of  half  or  an  entire  shaft  of  the  large,  long 
l)ones,  as  the  femur  or  humerus,  ma}-  require  from  three  to  six  months. 
If  the  patient's  general  health  is  improving  there  is  no  need  of  haste  in 
the  removal  of  a  sequestrum,  as  there  is  notliing  lost  and  a  great  deal 
gained  by  waiting  until  sufficient  time  has  elapsed  for  separation  to  take 
place.  Sequestrotomy,  if  properly  performed,  is  one  of  the  most  grateful 
of  all  operations,  as  it  is  attended  by  little  or  no  danger  to  life,  and  is 
usually  followed  by  a  favorable  result.  Its  performance  has  been  greatly 
simplified  by  the  use  of  angesthetics  and  Esmarch's  constrictor. 

Since  Esmarch  taught  us  how  to  obtain,  by  a  very  simple  appliance, 
a  bloodless  condition  of  the  limb  during  the  operation,  the  surgeon  can 
make  the  necessary  dissection  with  the  same  degree  of  accuracy  as  in 
the  dissecting-room,  thus  avoiding  injury  of  important  vessels  and 
nerves,  which  formerly  occurred  quite  frequently  even  in  the  hands  of 
the  most  accomplished  surgeons.  Before  the  operation  the  entire  limb 
is  disinfected  and  rendered  bloodless  by  elevating  it  for  a  few  minutes, 
W'hen  an  Esmarch  constrictor  is  applied  on  the  proximal  side  and  some 
distance  from  the  seat  of  operation.  I  have  met,  in  my  practice,  with  2 
cases  of  paralysis  of  the  musciilo-spiral  nerve  from  the  use  of  Esmarch's 
constrictor,  which  was  applied  about  the  middle  of  the  arm,  and, 
although  both  patients  recovered  perfect  use  of  the  limb  in  the  course 


252  I'KINCIPLES   OF    SURGEKY. 

of  two  to  four  months,  I  have  since  taken  the  precaution  to  guard 
against  such  a  perplexing  accident  by  appl3'ing  the  constrictor  over  the 
middle  of  the  deltoids,  and  over  several  thicknesses  of  a  towel  in  order 
to  protect  the  nerves  against  undue  pressure.  Since  I  have  made  use  of 
these  precautions  I  have  had  no  further  accidents  from  elastic  constric- 
tion. In  an  operation  for  extensive  necrosis  of  the  tibia  the  constrictor 
was  applied  just  above  the  knee,  and  as  soon  as  the  patient  recovered 
consciousness  it  became  evident  that  the  constriction  had  resulted  in 
paralysis  of  the  i)eroneal  nerve.  More  than  four  months  elapsed  before 
function  was  completely  restored.  Since  that  time  I  always  apply  the 
constrictor  higher  up,  where  the  nerves  are  protected  by  a  thick  cushion 
of  muscular  tissue,  and  have  seen  no  more  evil  elfects  from  elastic  con- 
striction of  the  lower  extremity.  Wherever  it  is  safe  to  make  the 
incision  in  the  line  of  one  or  more  fistulous  openings  this  should  be 
done,  but  when  these  are  in  localities  w^here  there  would  be  danger  of 
wounding  important  vessels,  muscles,  or  nerves,  another  location  must 
be  chosen.  In  operations  upon  the  humerus  the  exact  location  of  the 
musculo-spiral  nerve  must  be  remembered,  and  if  the  incision  necessarily 
comes  close  to  this  structure  the  dissection  is  made  slowly  and  with  the 
use  of  blunt  instruments  until  the  nerve  is  found,  when  it  can  be  held 
out  of  the  way.  In  operations  upon  the  lower  end  of  the  femur,  even 
if  the  fistulous  opening  should  be  in  the  popliteal  space,  the  incision  down 
to  the  bone  should  be  made  in  the  course  of  the  intermuscular  septum, 
on  the  outer  or  inner  side,  as  the  posterior  surface  of  the  femur  can  be 
made  accessible  from  either  side  by  making  the  incision  large  and  by 
keeping  close  to  the  bone,  separating  the  soft  tissues  well  and  keeping 
them  out  of  the  way  by  the  use  of  retractors.  Where  the  bone  is  cov- 
ered by  thick  layers  of  muscles  the  incision  is  made  in  the  direction  of 
the  muscles,  and  at  a  point  corresponding  to  an  intermuscular  septum. 
The  external  incision  should  always  be  large,  so  as  to  aftord  plenty  of 
space.  As  soon  as  the  intermuscular  septum  is  reached  the  scalpel 
should  be  laid  aside  and  the  parts  carefully  separated  down  to  the  bone 
by  using  the  fingers  or  blunt  instruments.  When  the  bone  is  reached 
the  periosteum  is  incised  and  reflected  with  the  soft  tissues  attached  to 
it.  The  opening  of  the  involucrum  is  done  with  the  chisel.  In  old- 
standing  cases  the  involucrum  is  as  dense  as  ivory  and  the  chiseling  is 
an  exceedingly  slow  and  laborious  process,  as  only  very  small  chii)s  cnn 
be  removed  with  each  cut  of  the  chisel.  The  brittleness  of  the  new 
bone  should  wai-n  the  surgeon  to  chisel  with  care,  as,  otherwise,  a  frac- 
ture might  result.  If  the  chiseling  is  done  at  the  site  of  a  former  open- 
ing, this  opening  is  enlarged  until  the  sequestrum  is  reached  and  can  be 
extracted.     Extraction  of  the  sequestrum  was  the  sole  object  of  opera- 


TREATMENT.  253 

tions  in  the  past ;  hence  the  dead  bone  was  removed  through  a  compara- 
tivel}'  small  opening  in  the  bone,  either  in  toto  or  after  fragmentation. 
Modern  surgery  not  only  seeks  to  remove  the  dead  bone,  but  to  place  the 
cavity  in  the  best  possible  position  for  rapid  healing.  The  first  indica- 
tion to  be  fulfilled  in  securing  a  favorable  reparative  process  after  the 
operation  is  to  obtain  an  aseptic  condition  of  the  cavity.  This  can  only 
be  done  by  exposing  the  interior  of  the  entire  cavitj'.  Chiseling  is  con- 
tinued until  both  ends  of  the  cavity  are  reached,  when  the  sequestrum 
can  be  lifted  out  and  the  granulations  lining  the  cavit}'  are  scraped  out 
with  a  sharp  spoon.  Spoons  of  different  sizes  should  be  at  hand,  as  the 
interior  of  such  cavities  usually'  present  depressions  and  sinuses,  which 
can  be  only  dealt  with  successfully  by  keeping  on  hand  different-sized 
spoons.  After  the  mechanical  removal  of  the  infected  tissues  the  cavity 
is  washed  out  with  a  solution  of  corrosive  sublimate  (1  to  1000)  and 
rubbed  out  and  dried  with  an  antiseptic  sponge.  It  is  evident  that  the 
healing  of  such  a  cavity,  by  unaided  resources  of  nature,  would  be  a 
slow  process.  Various  attempts  have  been  made  to  overcome  the  diffi- 
culties in  the  healing  of  cavities  with  unjielding  walls.  D.  J.  Hamilton 
suggested  sponge-grafting.  Neuber  made  flaps  of  the  skin  from  each 
side,  which  he  fastened  to  the  floor  of  the  cavity  with  bone  nails. 

Schede  utilized  the  blood,  which  he  allow^ed  to  accumulate  in  the 
cavity  after  suturing  the  external  parts,  and  obtained  some  excellent 
results  with  this  treatment.  Recently,  E.  Hahn  advised  to  detach  the 
skin  on  each  side  to  within  an  inch,  at  the  posterior  surface  of  the  limb, 
for  the  purpose  of  better  immobilization  of  the  flaps,  which  are  to  be 
mitted  over  the  centre  of  the  gutter  by  suturing.  For  some  years  the 
author  has  been  experimenting  on  animals  with  decalcified  bone  in  the 
healing  of  aseptic  bone-cavities,  and  the  experimental  as  well  as  the 
clinical  results  obtained  so  far  exceed  all  expectations.  The  decalcified 
bone-chips  are  i)reserved  in  an  alcoholic  solution  of  corrosive  sublimate 
(1  to  500)  or  a  solution  of  iodoform  in  sulphuric  ether.  The  most  essen- 
tial condition  for  success,  in  the  treatment  of  bone  defects  b}'  implanta- 
tion of  decalcified  bone,  is  a  perfectly  aseptic  condition  of  the  tissue  to 
be  brought  in  contact  with  the  implanted  bone.  This  condition  is  easily 
procured  in  operations  on  bones  for  lesions  other  than  those  caused  b}' 
infection  with  pus-microbes,  such  as  tumors,  echinococcous  c^'sts,  and 
tuberculous  and  syphilitic  affections  uncomplicated  by  suppuration.  In 
the  surgical  treatment  of  these  affections,  after  the  removal  of  the  dis- 
eased tissue  the  seat  of  operation  must  be  aseptic,  if  the  ordinary-  pre- 
cautions in  the  prevention  of  infection  from  without  have  been  observed. 
In  sucli  cases  speedy  healing  of  the  external  wound  and  the  earl}-  partial 
or  complete  reproduction  of  the  lost  bone  are  assured.     The  next  most 


254  PRINCIPLES    OF    SURGERY. 

favorable  cases  for  this  procedure  ure  circumscribed  osteomyelitic  proc- 
esses in  the  epipbj^seal  extremities  of  the  long  bones,  as  we  observe  them 
in  cases  of  primary  circumscribed  epiphyseal  osteomyelitis,  or  in  the 
form  of  a  recurring  attack  in  the  same  i)lace,  perliaps  years  after  a  diffuse 
osteom^-elitis  of  the  entire  shaft.  This  method  of  treating  bone-cavities 
is  also  applicable  after  operations  for  necrosis  resulting  from  a  previous 
attack  of  acute  suppurative  osteomyelitis.  The  cavity  must  be  prepared 
for  tlie  implantation  of  decalcified  bone  in  tlie  manner  described  above. 
The  implantation  is  made  before  the  removal  of  the  constrictor,  in  order 
that,  after  this  is  done,  sullicient  blood  will  escape  to  fill  the  spaces  be- 
tween the  chips,  and  thus  serve  the  nseful  purpose  of  a  temporary  cement- 
substance.  After  the  cavity  has  been  dusted  over  lightly  with  iodoform, 
the  chips,  which  have  been  washed  previously  in  an  antiseptic  solution, 
are  dried  upon  a  gauze  compress,  and  are  then  poured  into  the  cavit}' 
until  this  is  packed  with  them  as  far  as  the  periosteum.  The  first  advan- 
tage derived  from  this  method  of  bone-packing  is  that  the  chips  serve  as 
an  antiseptic  tampon  which  arrests  the  free  oozing  from  the  surface  of 
the  bone,  which  alwa3's  takes  place  after  the  removal  of  the  constrictor. 
Some  blood  escapes  between  the  bone-chips  and  coagulates  at  once,  thus 
forming  a  desirable  and  useful  cement-substance  which  permeates  the 
entire  packing,  and  temporarily  glues,  as  it  were,  the  chips  together  and 
the  entire  mass  to  the  surrounding  tissues.  The  periosteum  should  be 
carefully  preserved  in  exposing  the  bone,  and,  after  implantation,  is 
sutured  over  the  surface  of  the  bone-chips  with  absorbable  aseptic  buried 
sutures.  If  the  bone  is  deeply  located,  it  may  become  necessary  to 
apply  a  second  and  third  row  of  buried  sutures  in  bringing  into  accurate 
apposition  other  soft  parts.  The  skin  is  finally  sutured  with  silk.  It  is 
of  the  greatest  importance  to  secure  accurate  apposition  of  the  divided 
soft  parts,  in  order  to  preserve  for  the  subjacent  bone  all  of  its  natural 
coverings.  In  some  instances  it  w^ould  be,  undoubtedly,  superfluous  to 
secure  any  form  of  drainage,  as,  when  the  cavit}'  is  perfectly  aseptic  and 
haemorrhage  is  not  in  excess  of  requirements,  healing  of  the  entire  wound 
would  be  accomplished  under  one  dressing.  Experience,  however,  has 
taught  me  that  tension  arising  from  extravasation  of  blood  often  exerts 
an  injurious  influence  upon  the  process  of  healing,  and  should  be  care- 
full}'  avoided.  As  it  is  desirable  to  heal  as  much  of  the  wound  as  possi- 
ble without  interfering  with  drainage,  an  absorbable  capillar}'  drain 
should  be  inserted  in  the  lower  angle  of  the  wound.  A  string  of  catgut 
twisted  into  a  small  cord  answers  an  admirable  purpose.  The  wound  is 
covered  with  a  strip  of  aseptic  protective  silk,  over  which  a  few  layers 
of  iodoform  gauze  are  applied.  Over  this  a  cushion  of  sublimated  moss 
is  placed,  with  a  thick  layer  of  salicylated  cotton  along  its  margins  for 


TREATMENT.  255 

the  purpose  of  guarding  more  securel}-  agiiinst  the  entrance  of  unfiltered 
air.  The  whole  of  the  dressing  is  retained  by  a  circular  gauze  bandage, 
evenly  and  smoothly  applied.  For  the  purpose  of  securing  absolute  rest 
for  the  limb,  it  is  placed  upon  a  posterior  splint  and  kept  in  a  slightl}^ 
elevated  position.  If  no  indications  arise,  the  first  dressing  is  not 
removed  for  two  weeks,  when  the  entire  wound  will  usually  be  found 
healed,  except  a  few  granulations  at  the  place  where  the  catgut  drain  was 
inserted.  A  smaller  antiseptic  compress  is  applied  and  the  limb  dressed 
in  a  similar  manner.  It  is  prudent  to  enforce  rest, — not  only  till  the 
external  wound  has  healed,  but  until  the  process  of  repair  in  the  interior 
of  the  bone  has  been  completed,  which  embraces  a  period  var^  iug  from 
four  weeks  to  three  months,  according  to  the  size  of  the  cavity  and  the 
age  of  the  patient.  If  an  operation  for  necrosis  with  implantation  of 
decalcified  antiseptic  bone-chips  is  followed  by  suppuration,  it  is  an  evi- 
dence that  antisepsis  was  imperfect,  and  such  cases  must  be  treated  upon 
the  same  principles  as  suppuration  in  other  localities.  If  suppuration 
take  place  soon  after  the  operation,  and  is  profuse,  it  is  probable  that  all 
of  the  bone-chips  will  have  to  be  removed  in  order  to  facilitate  the  dis- 
infection of  the  cavity.  If  it  develop  after  granulation  tissue  has  had 
time  to  form,  and  the  discharge  of  pus  is  moderate  in  quantity,  the  pros- 
pects are  that  the  bone  will  remain  and  serve  its  purpose  as  a  nidus  for 
the  granulation  tissue.  In  such  cases  an  antiseptic  irrigation  should  be 
made  everj^  three  or  four  days  until  suppuration  has  ceased.  If  the 
bone-chips  are  lost  b}'  suppuration,  or  have  to  be  removed  for  the  pur- 
pose of  a  more  thorough  disinfection  of  the  cavity,  no  attempt  should 
be  made  at  re-implantation  until  suppuration  has  been  arrested  ;  or,  in 
other  words,  until  the  cavity  has  become  lined  with  granulations,  and  is 
in  a  comparatively^  aseptic  condition  (when  the  time  for  secondary  im- 
plantation has  arrived).  After  the  cavit}'  has  been  irrigated  with  a  strong- 
antiseptic  solution  the  superficial  granulations  are  removed  with  a  sharp 
spoon,  and  it  is  packed  with  bone-chips,  which  are  implanted  in  the  same 
manner  as  in  the  treatment  of  a  recent  cavit^y. 

Complete  closure  of  the  external  wound  under  these  circumstances 
is  seldom  obtainable,  and  the  surface  of  the  exposed  portion  of  the  cavity 
should  be  provided  with  a  thin  layer  of  Schede's  moist  blood-clot. 
I  have  resorted  to  implantation  of  decalcified  antiseptic  bone-chips  in 
the  treatment  of  bone-cavities,  after  necrotomy  and  operations  for  tuber- 
culosis of  bone,  in  at  least  25  cases,  and  have  had  the  satisfaction  of 
healing  large  defects  without  a  drop  of  pus  under  one  or  two  dressings 
in  from  two  to  four  weeks.  Only  in  a  small  percentage  of  the  cases  was 
it  found  necessary  to  remove  the  packing,  and  in  most  of  these  secondary 
implantation  proved   successful.     Schede's  blood-clot  does  not  possess 


256  pHiNnrLKS  of  surgery. 

:uiy  niitiseptic  properties,  like  the  Ijoiie-cliips,  and  is  not  as  permanent  a 
structure.  Operntions  b^-  Neuber's  method  are  often  followed  by 
necrosis  of  tlie  (laps,  and  even  if  successful  the  lost  bone  is  not  restored. 
Implantation  of  decalcified  antiseptic  bone-chips,  in  the  treatment  of 
aseptic  bone-cavities,  is  preferable  to  the  use  of  viable  grafts,  as  the 
substance  used  is  not  onl}'  absolutely  aseptic,  but  possesses  also  valuable 
antise[)tic  properties,  which  must  be  looked  upon  as  a  valua])le  and 
important  quality  in  the  treatment  of  such  cases.  Reproduction  of  bone 
follows  almost  to  perfection  in  everj^  case  where  antisepsis  proves 
successful ;  hence  they  serve  the  same  purpose  as  viable  grafts,  as  far  as 
the  restoration  of  lost  tissue  is  concerned.  I  have  chiseled  a  wide  gutter 
in  the  humerus  and  tibia  almost  from  one  epiphysis  to  the  other,  for  the 
removal  of  large  sequestra,  and  have  seen  such  enormous  defects  restored 
after  implantation  with  bone-chips  in  a  few  weeks.  The  contour  of  the 
bone  is  restored  to  such  perfection  that  after  a  few  months  it  would  be 
difficult  to  tell  where  the  operation  was  performed.  The  bone-chips 
serve  as  a  temporary  scaffolding  for  the  granulations  springing  from  all 
sides  of  the  bone-cavity,  and  as  the}'  are  removed  by  absorption  their 
place  is  occupied  by  living  permanent  tissue ;  first  by  embryonal  cells, 
"which  are  later  converted  into  bone. 

CHRONIC    CIRCUMSCRIBED    SUPPURATIVE   OSTEOMYELITIS. 

This  is  the  bone-abscess  of  the  older  authors.  The  etiology  of  this 
form  of  suppurative  inflammation  is  the  same  as  in  the  diffuse  variety. 
Clinicall}',  two  kinds  can  be  distinguished :  1.  Primarj-  epiphyseal 
circumscribed  osteomyelitis.  2.  Secondary  circumscribed  osteomyelitis. 
The  first  kind  is  occasionally  met  with  as  a  multiple  affection,  and  is 
then  attended  by  more  or  less  constitutional  disturliances  and  maj^  result 
in  epiph3'seol3'sis.  The  secondar}'  form  occurs  in  bones  that  have  been 
the  seat  of  an  attack  of  dittuse  suppurative  osteomyelitis,  the  patient 
apparently  having  recovered  completel}'  from  the  primary  attack  years 
before.  It  is  still  a  question  under  discussion,  if  in  these  cases  the 
infection  is  caused  b}'  microbes  which  have  remained  in  the  tissues  in  a 
latent  state  since  the  primary  attack,  or  whether  it  is  caused  by  localiza- 
tion of  pus-microbes  in  the  tissues  weakened  by  the  first  attack.  Rosen- 
bach  is  of  the  opinion  that  recurring  attacks  of  osteomyelitis  in  the  same 
bone  are  caused  b}'  pus-microbes  which  have  remained  in  the  tissues,  and 
which  again  become  pathogenic  when  the  tissues  around  them  are 
rendered  susceptible  to  their  action  by  subsequent  causes.  I  am 
strongl}^  inclined  to  the  same  opinion.  I  have  seen  numerous  cases 
where,  in  persons  from  16  to  25  years  of  age,  repeated  attacks  of  circum- 
scribed osteomyelitis  occurred  in  a  bone  which,  during  childhood,  had 


CHRONIC    CIRCUMSCRIBED    SUPPURATIVE    OSTEOMYELITIS.       257 

passed  through  an  attack  of  acute  osteomj-elitis.  The  tibia,  femur,  and 
humerus  are  the  bones  which  are  most  frequentl}'  attacked  b}'  recurrent 
osteom3elitis.  The  secondary  attacks  occur  either  in  the  centre  of  the 
sclerosed  bone,  the  former  site  of  the  infected  medullary  cavity,  or  near 
one  of  the  epiphyseal  lines.  I  have  no  doubt  that  secondarj-  osteo- 
myelitis will  be  of  less  frequent  occurrence  after  earl}'  operations  for 
osteomjelitis,  and  that  antiseptic  sequestrotomy  will  be  more  generally 
practiced. 

Symptoms. — The  most  important  symptoms  of  circumscribed  central 
suppuration  in  bone  are  pain  and  tenderness.  The  pain  is  deep-seated, 
intense,  of  a  boring  or  gnawing  character,  and  is  generally  more  severe 
after  active  exercise  and  during  the  night.  It  is  often  intermittent,  and 
lias  frequently'  been  wronglj-  interpreted  as  neuralgia  of  bone. 

The  tenderness  is  circumscribed,  and  corresponds  to  the  location  of 
the  suppurating  focus.  It  is  due  to  a  circumscribed  secondary  plastic 
periostitis.  The  external  swelling  is  slight,  and  often  completely'  wanting. 
Usually  neither  redness  nor  oedema  are  present. 

Pathological  Anatomy. — Limited  suppurative  osteom3elitis  gives  rise 
to  a  circumscribed  abscess,  which  varies  in  size  from  a  pea  to  a  walnut. 
Necrosis  of  bone  seldom  takes  place;  if  it  does,  the  sequestra  are  small 
and  composed  exclusively'  of  cancellated  tissue.  If  the  abscess  is  situated 
in  an  epipln'sis  it  ma}'  open  into  the  adjacent  joint  and  become  the  cause 
of  a  secondar}'  suppurative  arthritis.  Thrombo-phlebitis,  sepsis,  and 
pyaemia  rarely  occur.  The  periostitis  which  attends  chronic  suppuration 
in  bone  always  assumes  a  plastic  type,  as  the  periosteum  is  beyond  the 
reach  of  pus-microbes.  Epiphyseal  osteomyelitis  is  often  associated  with 
chondritis  and  osteoporosis, — conditions  which  may  result  in  pathological 
fracture.  If  in  this  form  of  osteomyelitis  the  sii[)iiuration  extend  to 
the  periosteum,  a  circumscribed  suppurative  periostitis  occurs,  which  is 
followed  by  the  formation  of  small  abscesses  in  the  epiphyseal  region. 
Limited  necrosis  in  these  cases  is  of  frequent  occurrence. 

Treatment. — Circumscribed  osteomvelitic  processes  in  the  epiphyseal 
extremities  of  the  long  bones,  as  we  observe  them  in  cases  of  primary 
circumscribed  suppuration  in  the  epiphyseal  region,  or  in  the  form  of  a 
recurring  attack  in  the  same  place  or  in  the  sclerosed  shaft,  perhaps 
years  after  a  diffuse  osteomyelitis  of  the  entire  shaft,  are  favorable  cases 
for  implantation  of  decalcified  antiseptic  bone-chips,  as  an  aseptic  con- 
dition of  the  cavity  can  be  readily  procured  after  the  operative  removal 
of  the  infected  tissues.  The  inflammatory  focus  can  be  located  externally 
with  accurac}'  by  the  presence  of  a  circumscribed  area  of  tenderness, 
and  the  centre  of  the  tender  spot  constitutes  the  guide  in  the  search  for 
the  abscess.     The  operation  is  performed  under  strict  antiseptic  precau- 


258  PRINCIPLES   OF   SURGERY. 

tions,  and  by  the  bloodless  method.  The  chiseling  is  done  in  the  direc- 
tion of  the  centre  of  the  bone  by  making  a  track  perhaps  an  inch  sqnare. 
If  the  abscess  is  not  fonnd  at  a  certain  depth  the  surrounding  tissue  is 
explored  with  a  small  drill,  in  difl'erent  directions  from  the  track,  until 
it  is  discovered,  when  further  excavation  is  again  made  with  the  chisel. 
As  soon  as  the  abscess  has  been  full}-  exposed  the  pus  is  washed  out, 
and  the  size  of  the  cavity  ascertained  by  probing.  As  the  abscess  is 
often  surrounded  by  a  zone  of  tissne  infiltrated  with  pus,  all  of  the 
infected  tissues  arc  scraped  ont  thoroughly  with  a  sharp  spoon  ;  after 
which  the  cavity  is  prepared  for  the  implantation  of  the  bone-chips  in 
the  same  manner  as  in  operations  for  necrosis.  lodoformization  of  the 
cavit}^  and  the  implantation  of  antiseptic  bone-chips  are  measures  which 
are  well  calculated  to  resist  the  pathogenic  action  of  pus-microbes  which 
might  still  remain,  and  in  the  majority  of  cases  will  secure  an  aseptic 
healing  of  the  wound.  I  have  repeatedly  seen  cavities  the  size  of  a 
small  orange,  in  the  head  of  the  tibia,  heal  under  two  dressings,  wnth 
perfect  restoration  of  the  bone  removed  by  this  method  of  treatment. 
The  means  resorted  to  to  obtain  an  aseptic  condition  of  the  cavity  will 
often  result  in  increase  to  twice  its  original  size,  but  the  loss  of  tissue 
is  not  to  be  taken  into  consideration  when  a  method  of  treatment  is  to 
be  employed  which  requires  perfect  asepsis  in  order  to  be  successful  in 
placing  the  parts  in  a  condition  where  perfect  restoration  will  be 
accomplished  with  almost  unfailing  certaint3\ 


CHAPTER  XI. 

Suppuration  in  Large  Cavities  ;  Abscess  of  Internal  Organs. 

The  suppurative  afl'ections  of  the  ditl'erent  large  cavities  in  the  body 
present  so  nianv  features  common  to  all  of  them  that  they  will  be  con- 
sidered together  in  this  chapter.  Suppurative  inflammation  of  a  mem- 
brane, synovial  or  serous,  lining  a  closed  cavity,  is  characterized  b}-  the 
rapidit}^  with  which  the  inflammatory  process  spreads  over  the  entire 
surface,  and  the  retention  of  the  products  of  inflammation  in  a  preformed 
closed  space.  Abscesses  of  internal  organs  result  from  infection  by  the 
extension  of  a  suppurative  lesion  from  the  surface  along  the  course  of 
blood-vessels,  lymphatics,  nerve-sheaths,  or  b}'^  localization  of  pus- 
microbes  floating  in  the  blood  in  a  locus  minoris  resistentise  of  an  organ. 

suppurative  arthritis. 

Suppurative  inflammation  in  an  intact  joint  is  alwaj^s  caused  by 
localization  of  pus-microbes  in  the  sj^novial  membrane,  conveyed  to  this 
structure  by  the  blood,  which  results  in  suppurative  synovitis,  and,  by 
the  extension  of  the  infection  to  the  other  structures  of  the  joint,  is 
often  followed  by  complete  disorganization  of  the  joint.  In  this  manner 
metastatic  suppurative  synovitis  is  caused,  as  it  occurs,  in  p3'aemia, 
gonorrhoea,  and  in  some  of  the  general  infective  diseases. 

Bacteriological  Researches. — In  animals  susceptible  to  the  action 
of  pus-microbes,  the  injection  into  a  joint  of  a  pure  culture  is  nsuall}^ 
followed  by  acute  suppuration,  and,  not  infrequently,  by  the  formation 
of  extensive  para-articular  abscesses.  Hoffa,  Kranzfeld,  and  Krause  have 
studied,  with  special  care,  the  microbic  origin  of  suppurative  S3^no- 
vitis,  and  all  of  them  found  in  the  pus  one  or  more  varieties  of  the 
microbe  of  suppuration.  Krause  found,  in  the  pus  of  suppurating  joints 
in  small  children,  a  streptococcus,  the  identity  of  which  with  the  one 
described  b}^  Rosenbach  was  proved  by  cultivation  experiments.  In 
one  case  the  same  microbe  was  also  found  in  the  products  of  a  purulent 
meningitis,  which  followed  in  the  course  of  the  joint  disease.  The  same 
streptococcus  was  found  by  Heuber  and  Bahrdt  in  pus  from  a  suppurat- 
ing joint,  and  in  the  diphtheritic  membranes  of  a  scarlet-fever  patient. 
The  so-called  gonorrhoeal  rheumatism  is  a  suppurative  S3'novitis,  but 
opinions   are  divided   in   reference   to  the  p^-ogenic  properties  of  the 

(259) 


260  PRINCIPLES    OF    SURGERY. 

gonococcus.  This  microbe  was  discovered  in  gonorrhoeal  pus  hy  Neisser, 
in  1879.  Its  direct  etiological  relation  to  gonorrhoea  has  been  sufficiently 
demonstrated  by  experimental  research  and  clinical  observation.  The 
gonococcus  always  occurs  in  pairs,  and  is,  therefore,  a  diplococcus. 

The  cocci  appear  as  hemispherical  bodies,  with  their  flattened  sur- 
faces in  apposition,  which  imparts  to  the  microbe  the  characteristic 
biscuit-shaped  appearance.  They  are  found  in  clusters  upon,  or,  what 
is  more  probable,  as  Biimni  asserts,  within  the  pus-corpuscles  of  gonor- 
rhoeal pus.  Their  intra-cellular  location  was  shown  b}-  Bumm,  b^^  exam- 
ining pus-corpuscles  in  water  ;  when,  after  imbibition  of  fluid,  the  cells 
became  swollen,  the  cocci  could  be  seen  between  the  molecular  granules 
of  the  protoplasm.  The  microbes  within  the  corpuscles  ma}^  become  so 
numerous  as  to  fill  the  entire  space,  with  the  exception  of  the  nucleus. 
It  can  be  cultivated  upon  solidified  blood-serum,  or  agar-agar-meat 
peptone.  Its  pus-producing  property  in  specific  inflammation  of  the 
mucous  membrane  of  the  urinary  organs  and  conjunctiva  is  well  known, 


Fig.  61.— Gonococcus.    {Bumm.) 

A.  From  a  pure  culture.  B.  From  a  blennorrhceic  conjunctival  secretion  ;  an  epithelial  cell  covered 
with  cocci;  a  pus-corpuscle  with  cocci  in  the  protoplasm;  a  pus-corpusele  completely  filled  with  cocci; 
a  free  mass  of  cocci  in  close  proximity  to  a  pus-corpuscle.     C.  Development  of  gonococci. 

and  at  present  is  not  attributed  to  its  direct  efl'ect  on  the  tissues,  but  to 
the  action  of  ptomaines,  which  it  produces.  A  number  of  cases  have 
been  reported  which  appear  to  show  that  under  certain  circumstances 
the  microbe  enters  the  circulation  and  becomes  the  cause  of  metastatic 
suppuration,  especialljMn  joints.  Schwarz  asserts  that  the  gonococcus 
is  constantly  found  in  the  eff"usion  of  joints  in  gonorrhoeal  rheumatism, 
in  other  abscesses  caused  by  gonorrhoea,  and  in  the  glands  of  Bartholin, 
in  women  who  have  passed  through  an  attack  of  gonorrhoea.  Petrone 
detected  the  gonococcus  in  the  effusion  of  joints  and  in  the  blood,  in 
two  patients  suffering  from  gonorrhoeal  rheumatism.  He  regards  the 
joint  complications  as  metn static  processes  caused  by  the  gonorrhoeal 
infection.  Other  authors  found  metastatic  abscesses  in  gonorrhoeal 
patients,  cultivated  from  the  pus-microbes  of  suppuration,  and  on  this 
account  regard  them  as  the  result  of  a  secondary-  or  mixed  infection. 
If  gonococci  can  transform  epithelial  cells  of  the  urethra  or  conjunctiva 
into   pus-corpuscles,  there   is  no  renson  to  doubt  that  under  favorable 


SUPPURATIVE    ARTHRITIS.  261 

circumstances  they  can  exercise  the  same  pathogenic  eftect  on  other 
tissues,  particularly  the  synovial  membrane  of  joints. 

Symptoms  and  Diagnosis. — Suppurative  arthritis  is  usuall}- attended 
b}'  a  great  deal  of  pain.  This  symptom  is  a  prominent  one  in  this  affec- 
tion on  account  of  the  intensity  of  the  inflammation,  and  also  because 
the  pus  accumulates  with  great  rapidit}^  in  the  joint,  causing  tension, 
x^octurnal  exacerbations  are  common.  The  pain  is  greatly  aggravated 
bj-  passive  motion,  and  any  attempt  on  the  part  of  the  patient  to  use  the 
joint  vastl}"  increases  the  suffering.  Flexion  of  the  joint  is  an  early 
symptom,  and  increases  in  degree  with  the  progress  of  the  disease.  In 
suppurative  inflammation  of  the  hip-  and  knee-joint  it  is  not  uncommon 
to  find  the  limb  flexed  at  right  angles.  In  advanced  cases  of  suppura- 
tive gonitis  the  tibia  becomes  partially  dislocated  backward  and  rotated 
outward.  The  swelling,  as  long  as  it  is  caused  In'  the  effusion  into  the 
joint,  is  proportionate  to  the  amount  of  fluid  contained  in  the  joint.  In 
the  knee-joint  the  patella  is  raised  from  the  condyles  of  the  femur,  the 
depressions  on  each  side  of  it  are  effaced,  and  the  upper  recesses  of  the 
sj-novial  sac  become  prominent.  After  perforation  of  the  capsule,  the 
pus  escapes  into  the  loose  para-articular  connective  tissue,  where  it 
causes  a  rapidly-spreading  phlegmonous  inflammation.  In  \evy  acute 
cases  rupture  of  the  capsule  and  an  extensive  para-articular  abscess  may 
appear  in  less  than  a  week.  With  the  rupture  of  the  capsule  of  the  joint 
the  pain  is  diminished,  but  the  general  symptoms  are  aggravated.  The 
parts  around  a  suppurating  joint  usuall}-  present  an  oedematous  appear- 
ance. The  clinical  history  is  often  of  great  value  in  arriving  at  a  con- 
clusion in  reference  to  the  character  of  the  synovitis.  If  an  arthritis 
develop  insidioush*  in  connection  with  a  suppurating  lesion,  attended 
by  grave  general  sj-mptoms,  it  is  an  evidence  which  renders  a  diagnosis 
of  pyaemia  more  than  probable.  In  p^'aemia  the  joint  affections  appear 
often,  either  simultaneousl}-  or  in  rapid  succession,  as  multiple  afl^ections. 
An  obstinate  joint  affection,  appearing  in  the  course  of  an  attack  of 
gonorrhoea,  is  generally  either  a  sero-purulent  or  suppurative  s3'novitis. 
Gonorrhoeal  synovitis  develops  most  frequently'  from  the  second  to  the 
fourth  week  after  the  appearance  of  the  primary  disease.  If  anj'  doubt 
exist  as  to  the  character  of  the  effusion  into  a  joint,  this  can  be  readily 
dispelled  bv  making  an  exploratory-  puncture  with  an  ordinary'  hypo- 
dermic needle. 

Treatment. — Tlie  only  form  of  suppurative  sj-novitis  amenable  to 
any  other  treatment,  short  of  free  incision,  drainage,  and  antiseptic  irri- 
gation, is  the  sero-iMirulent  effusion  complicating  gonorrhoea.  In  such 
cases  aspiration,  followed  b}-  compression  of  the  joint  and  fixation  of 
the  limb  in  an  immovable  dressing,  is  usuall}'  successful  in  permanently 


262  PRINCIPLES   OF    SURGERY. 

removing  the  effusion.  The  absorption  of  the  products  of  inflammation 
and  return  of  function  are  hastened  by  massage  and  liot  and  cold  douches. 
If  a  joint  contain  pus,  temporizing  measures  should  be  abandoned,  and 
the  pus  should  be  evacuated  either  by  aspiration  followed  by  washing 
out  with  an  antiseptic  solution,  which  should  be  repeated  until  the  fluid 
returns  clear,  or,  wliat  is  preferable  in  the  vast  majority  of  cases,  the 
joint  is  treated  from  the  beginning  as  an  ordinary  abscess.  For  irriga- 
tion of  asuppurating  joint  with  the  aspirator,  a  ^-per-cent.  (.5  per  cent.) 
solution  of  acetate  of  aluminum  should  be  \ised.  The  greatest  care  must 
be  exercised  not  to  inject  atmospheric  air  into  the  joint,  as,  aside  from 
the  danger  of  increasing  the  infection  b}^  the  admission  of  air,  such  acci- 
dents have  been  followed  b}'  immediate  death  from  air  embolism.  The 
most  eflficient  treatment  in  cases  of  suppurative  arthritis  is  incision  and 
drainage  under  strictest  antiseptic  precautions.  As  in  the  treatment  of 
acute  abscesses,  the  incisions  must  be  made  in  places  where  drainage  is 
most  required.  A  long  pair  of  haemostatic  forceps  is  an  indispensable 
instrument  in  draining  a  joint.  In  draining  the  knee-joint  three  trans- 
verse tubular  drains  should  be  inserted,  one  beneath  the  tendon  of  the 
patella,  one  under  the  patella,  and  one  across  the  upper  recess  of  the 
joint.  The  fourth  drain  should  be  passed  directly  through  the  joint 
between  the  condyles  of  the  femur,  reaching  from  one  side  of  the  patella 
into  the  popliteal  space.  This  would  require  eight  incisions,  each  from 
^  to  1  inch  in  length  ;  half  of  them  serve  as  openings  into  the  joint  for 
the  forceps,  while  in  making  the  remaining  incisions  only  the  skin  and 
fascia  are  cut  to  the  requisite  extent  over  the  point  of  the  forceps.  In 
tunneling  the  soft  tissues  in  tlie  popliteal  space,  with  the  forceps,  from 
within  outward,  the  opening  is  to  be  made  to  one  side  of  the  large  vessels 
and  nerves.  Such  an  operation  requires  the  administration  of  an  anaes- 
thetic and  the  use  of  elastic  constriction  of  the  limb. 

As  soon  as  all  the  drains  are  inserted  the  joint  is  washed  out  in 
different  directions  with  one  of  the  stronger  antiseptic  solutions,  after 
which  a  copious  antiseptic  dressing  is  applied  and  the  limb  is  immobil- 
ized upon  a  splint.  If  on  the  following  day  the  fever  has  not  subsided, 
or  as  soon  as  the  dressing  has  become  saturated  with  the  discharges,  it 
is  removed,  and  the  irrigation  repeated  as  before.  As  soon  as  suppura- 
tion diminishes,  through  drainage  is  dispensed  with  and  the  drains  are 
shortened  from  time  to  time,  to  be  entireh'  removed  with  the  disappear- 
ance of  the  swelling  and  the  cessation  of  suppuration.  The  elboAv-joint 
can  be  efficiently  drained  by  passing  a  drain  transversel}'  through  the 
joint,  between  the  articular  surfaces  of  the  humerus,  radius,  and  ulna. 
In  draining  the  ankle-joint,  a  small  incision  is  made  down  into  the  joint, 
at  a  point  corresponding  to  the  anterior  margin  of  the  external  malleolus, 


ENDOCRANIAL    SUPPURATION.  263 

through  which  a  haemostatic  forceps  is  introduced  and  pushed  in  a 
backward  direction,  along  the  upper  surface  of  the  astragalus,  until  its 
point  can  be  felt  posteriorly  under  the  skin,  to  the  outer  side  of  the 
tendo  Achillis.  The  skin  is  then  incised,  the  opening  enlarged  by  un- 
locking the  forceps  and  separating  its  blades,  and  a  fenestrated  rubber 
drain  drawn  through.  If,  as  it  so  often  happens,  the  posterior  portion  of 
the  capsule  of  the  joint  bulge  considerably,  this  can  be  drained  b}'  a 
drain  inserted  transversely  underneath  the  tendo  Achillis,  near  its  attach- 
ment to  the  OS  calcis.  Through  drainage  of  the  shoulder-joint  in  an 
antero-posterior  direction  can  be  established  in  the  same  manner  without 
much  difficult}-.  Drainage  of  the  hip-joint  is  alwa3S  difficult  and  never 
efficient.  The  best  plan  to  follow  is  to  open  the  joint  from  behind 
through  an  incision  tliree  or  four  inches  in  length,  and  then  to  pass  a 
long  pair  of  Peau's  or  polypus  forceps  between  the  capsule  and  the  neck 
of  the  femur,  either  along  the  upper  or  lower  border,  in  the  direction  of  the 
groin,  and  to  make  a  counter-incision  upon  the  point  of  the  instrument, 
and  to  draw  a  tubular  drain  through  the  whole  length  of  the  track.  The 
wrist-joint  can  be  drained  transversel}'  and  antero-posteriorly,  without 
fear  of  injuring  any  important  structures.  If  suppuration  continue,  in 
spite  of  free  drainage  and  careful  antiseptic  after-treatment,  threatening 
the  life  of  the  patient  from  exhaustion  or  sepsis,  more  aggressive  measures 
are  indicated.  Under  such  circumstances,  it  becomes  often  an  exceed- 
ingly difficult  matter  to  decide  which  one  of  the  operative  procedures 
should  be  adopted, — arthrectomy,  excision,  or  amputation.  If  the  pa- 
tient's strength  is  so  much  reduced  that  artlirectomy  or  excision  offer  no 
prospects  of  a  successful  issue,  amputation  should  be  performed.  This 
alternative  becomes  an  unavoidable  necessity  if  the  suppurative  arthritis 
is  complicated  by  extensive  burrowing  of  pus  among  the  muscles,  ten- 
dons, and  para-articular  tissues.  If  the  patient's  strength  warrant  an 
arthrectomy,  this  operation  should  be  done  if  the  disease  is  limited  to  the 
synovial  membrane  of  the  joint.  Tj'pical  or  at3'pical  resection  is  to  be 
restricted  to  cases  where  the  articular  cartilages  and  bone  itself  are  found 
diseased.  In  resection  of  joints  for  suppurative  affections,  the  surgeon 
must  aim  to  remove  onl}-  infected  tissues;  hence  incomplete  atypical  are 
more  frequently  indicated  than  complete  or  tyi)ical  resections.  All 
cases  of  suppurative  inflammation  of  joints  should  be  treated  from  the 
beginning  b}-  immobilization  of  the  limb  and  by  the  use  of  an  ai)pro- 
priate  mechanical  support,  both  for  the  purpose  of  securing  rest  and  to 
prevent  deformities. 

ENDOCRANIAL    SUPPURATION. 

(a)  Suppurative  Pachymeningitis. — Suppurative  inHamnmtion  of  the 
dura  mater  occurs  either  as  a  circumscribed  or  diffuse  affection.     It  is 


201  PRINCIPLES   OF    SURGERY. 

caused  b}'  direct  or  indirect  iiilection  with  pus-microhes.  Direct  infec- 
tion occurs  when  the  membrane  is  in  communication  witli  an  infected 
penetrating  wound  of  tlie  skull.  Traumatism,  without  infection,  never 
results  in  suppurative  inflammation  of  the  envelopes  of  the  brain  ;  nor 
does  the  presence  of  an  aseptic  foreign  body  produce  it.  Aseptic 
injuries  of  the  brain  and  its  envelopes  are  productive  of  circumscribed, 
degenerative,  or  plastic  lesions,  but  no  suppuration.  Septic  inflamma- 
tion of  these  structures,  on  the  other  hand,  is  noted  for  its  tendenc}^  to 
become  diffuse  and  to  extend  from  one  tissue  to  another,  both  b}'  con- 
tinuity and  contiguit}'.  Thus,  in  cases  of  pachymeningitis  with  loss  of 
continuity  of  the  dura  mater,  in  cases  of  compound  fractures  of  the 
skull,  resulting  from  infection  with  pus-microbes  from  without,  the  in- 
flammation commences  npon  the  outer  surface  of  the  membrane,  and  if 
the  pus-microbes  do  not  penetrate  the  tissues  the  suppurative  process 
remains  superficial ;  but,  as  is  more  frequently  the  case,  the  microbes 
wander  deeper  into  the  tissues,  until  the  entire  thickness  of  the  dura  has 
become  infected,  and  when  the  inner  surface  is  affected,  the  underlying 
membranes,  the  arachnoid  and  pia  mater,  as  well  as  the  surface  of  the 
brain  itself,  are  liable  to  become  involved,  step  b}^  step,  b}'  the  extension 
of  the  infection  from  meml)rane  to  membrane  and  surface  to  surface. 
Suppurative  pach3'meningitis  may  remain  as  a  circumscribed  affection, 
and,  if  the  internal  surface  of  tlie  dura  is  the  seat  of  suppuration,  it 
results  in  the  formation  of  a  subdural  abscess.  In  circumscribed  sub- 
dural suppuration,  the  diffusion  of  the  pus  between  the  dura  mater  and 
the  arachnoid  is  prevented  b}-  a  plastic  exudation,  which  cements  the 
two  membranes  together.  In  suppurative  pach^'meningitis,  affecting 
only  the  inner  surface  of  the  dura,  w^e  often  find  a  subcranial  abscess, 
the  outer  wall  of  which  is  formed  by  the  skull  and  the  inner  by  the 
dura  mater.  The  mechanical  effect  of  the  presence  of  pus  in  either 
locality  will  give  rise  to  the  same  group  of  cerebral  symptoms.  Indirect 
infection  of  the  dura  mater  with  pus-microbes  occurs  in  cases  of  suppu- 
ration in  the  epicranial  tissues  and  in  suppurative  osteom3^elitis  of  the 
cranial  bones,  bj-  extension  of  the  infection  along  the  course  of  blood- 
vessels. In  this  way  an  insignificant  peripheral  suppurative  lesion  of 
the  coverings  of  the  skull  is  often  followed  by  a  grave  form  of  endo- 
crnnial  suppurntion. 

Symptoms  and  Diagnosis. — Diffuse  septic  pach^-mcningitis  is  alwa3%s 
attended  by  inflammation  of  the  arachnoid,  pia  mater,  and  cortex  of  the 
brain,  and  the  symptoms  point  more  toward  a  cortical  encephalitis  than 
a  pachjMneningitis.  Localized  suppurative  pachj'meningitis  gives  rise  to 
sj'mptoms  which  indicate  the  presence  of  a  phlegmonous  inflammation, 
modified  in  this  instance  by  symptoms  arising  from  mechanical  disturb- 


ENDOCRANIAL    SUPPURATION.  265 

ances,  caused  by  the  presence  of  inflamuiator}'  exudation,  or  the  partici- 
pation of  the  surface  of  the  brain  in  the  suppurative  process.  In  the 
acute  septic  form,  following  a  compound  fracture  of  the  skull,  the  first 
S3-mptoms  are  observed,  usually,  during  the  second  or  third  day  after 
the  injur}-,  and  rapidly  increase  in  intensity'  from  the  progressive  exten- 
sion of  the  infection.  In  the  circumscribed  form  the  symptoms  are 
more  localized.  The  headache  is  often  severe,  especially  if  the  inflam- 
mation is  located  upon  the  inner  surface  of  an  intact  dura,  and  involves 
a  corresponding  extent  of  the  subjacent  membranes  and  cortex  of  the 
brain.  The  earl^'  symptoms  are  those  of  irritation,  to  be  followed,  as 
the  accumulation  of  pus  increases,  by  evidences  of  compression.  B}^ 
means  of  focal  symptoms  it  is  often  possible  to  locate  the  seat  of  the 
inflammatory  product  in  the  interior  of  an  intact  skull  with  sufficient 
accuracy  to  enable  the  surgeon  to  evacuate  the  pus  by  operative  measures. 
Acute  suppuration  between  the  surface  of  the  brain  and  the  inner  sur- 
face of  the  skull  is  alwaj's  attended  by  a  rise  in  the  temperature.  The 
pulse  is  accelerated,  at  first  full  and  bounding,  to  become  slower  and 
slower  as  compression  increases.  If  the  pulse,  in  a  case  of  endocranial 
inflammation,  has  been  gradualh'  reduced  from  120  to  35  or  40,  it  is 
a  sign  that  cerebral  compression  has  reached  the  maximum  extent  com- 
patible with  life,  and  when  it  again  reaches  its  former  frequency  it  is  an 
indication  that  dissolution  is  near  at  hand.  The  condition  of  the  dura 
mater  in  subdural  suppuration  is  of  great  importance  in  determining  the 
presence  or  absence  of  accumulation  of  pus.  In  compound  fractures, 
with  loss  of  bone-substance,  the  existence  of  a  subdural  abscess  is  indi- 
cated by  bulging  of  the  dura  into  the  opening  of  the  skull  and  absence 
of  cerebral  pulsations.  In  trephining  the  skull  for  a  supposed  endo- 
cranial abscess,  the  surgeon's  duty  is  to  explore  the  subdural  space,  or 
to  incise  the  dura  mater,  if  this  membrane  appear  tense  or  bulge  into  the 
opening,  and  if  cerebral  pulsations  cannot  be  seen  or  felt. 

Treatment. — The  successful  prevention  of  endocranial  infection  by 
rigid  antisejitic  precautions  in  compound  fractures  of  the  skull  and  endo- 
cranial operations  is  one  of  tlie  best  arguments  in  support  of  the  value 
of  the  antiseptic  treatment  of  wounds.  Intentional  opening  of  the 
skull  under  strict  antiseptic  precautions  is  seldom  followed  by  suppura- 
tive endocranial  inflammation.  Compound  fractures  of  the  skull  without 
fatal  injur}'  to  the  brain,  if  treated  by  strict  antiseptic  measures  soon 
after  the  receipt  of  the  injury,  generally  result  in  recovery  of  the  patient. 
The  most  important  indication  in  the  treatment  of  these  cases  is  to 
prevent  infection  of  the  wound,  and  thus  guard  most  effectively  against 
the  occurrence  of  endocranial  suppuration. 

In  the  treatment  of  compound  fractures  of  the  skull,  correction  of 


26()  PRINCIPLES   OF    SURGEKV. 

mechanical  difficulties  is  nothing  compared  with  the  importance  of  carry- 
ing out  full  antiseptic  precautious  to  prevent  the  fatal  complications. 
Suppurative  pachymeningitis  is  i)revented  by  the  same  treatment  wliich 
secures  an  ideal  aseptic  healing  in  wounds  of  other  parts.  The  prophy- 
lactic treatment  aims  at  obtaining  for  the  external  wound,  the  fractured 
bones,  and  the  exposed  spaces  underneath  them  a  perfectly  aseptic  con- 
dition. Tlie  entire  head  should  be  shaved  and  tlie  scalp  rendered 
aseptic,  by  washing  it  with  warm  water  and  i)otash-soap,  to  be  followed 
with  a  solution  of  corrosive  sublimate  (1  to  1000),  and,  lastly,  with  sul- 
phuric ether  or  alcohol.  The  wound  of  the  i)ericranial  tissues  is  en- 
larged sufficiently  to  admit  of  thorougli  disinfection  of  the  crevices 
between  the  fragments.  Blood-clots  and  otlier  foreign  substances  are 
to  be  sought  for  and  removed,  as  infection  is  often  traceable  to  imperfect 
treatment  in  this  regard.  Loose  fragments  are  removed  and  kept  in  a, 
warm  solution  of  corrosive  sublimate  until  they  are  re-implanted.  De- 
pressed fragments  are  elevated,  and  the  space  between  the  bone  and  the 
dura  disinfected.  If  the  dura  has  been  lacerated  the  disinfection  is 
carried  farther.  Detached  and  contused  brain-tissue  is  removed.  All 
haemorrhage  is  carefully  arrested,  and  after  the  final  irrigation  the  dura 
is  sutured,  and,  if  necessary,  a  capillar}^  drain  of  aseptic  catgut  or 
horse-hair  inserted. 

In  the  majorit}'  of  cases  it  is  advisable  to  drain  the  external  wound 
by  the  insertion  of  a  tubular  drain  at  the  most  dependent  point.  Re- 
tention of  the  antiseptic  dressing  is  secured  best  by  applying  a  few  turns 
of  a  plaster-of-Paris  bandage.  If,  in  spite  of  thorough  primary  disin- 
fection, asepsis  is  not  secured,  secondary  disinfection  is  to  be  instituted 
at  once.  This  requires  that  tlie  superficial  sutures  are  removed.  De- 
tached bone  is  not  to  be  re-implanted  a  second  time,  for  fear  of  renewed 
infection.  The  whole  surface  is  now  disinfected  by  filling  every  sinus 
and  depression  with  peroxide  of  hydrogen  After  effervescence  has 
ceased  the  fluid  is  washed  away  by  irrigation  with  the  ordinary  anti- 
septic solutions.  Tlie  peroxide  of  hydrogen  will  reach  parts  of  the 
infected  surface  inaccessible  to  other  antiseptic  solutions.  If  any 
evidences,  local  or  general,  point  to  the  existence  of  a  beginning  inflam- 
mation of  the  dura  mater  and  the  subjacent  membranes,  the  deepest 
portions  of  the  wound  are  subjected  to  thorough  disinfection  and  tubular 
subdural  drainage  is  established.  If  secondary  disinfection  prove  un- 
successful the  antiseptic  dressing  is  to  be  removed  and  the  moist  anti- 
septic compress  substituted,  which  is  removed  from  time  to  time,  when 
the  deeper  portions  of  the  wound  are  cleansed  by  irrigation  with  an 
antiseptic  solution. 

An  external  supimrsitive  pacli^'meiiiiigitis  is  treated  in  the  same  wa}' 


ENDOCRANIAL    SUPPURATION.  267 

as  an  infected  compound  fracture  of  the  skull.  If  it  follow  a  com- 
pound fracture,  loose,  detached  bones  are  removed,  and  the  whole  sup- 
purating surface  is  disinfected ;  after  which,  tubular  drainage  is  estab- 
lished. If  it  follow  a  fissured  fracture,  a  sufficiently  large  opening  is 
made  in  the  skull,  to  permit  of  free  disinfection,  and  the  accumulation 
of  pus  is  prevented  by  the  insertion  of  a  tubular  drain.  Suppuration 
between  the  dura  mater  and  the  cranial  vault  in  an  intact  skull  is  treated 
by  making  one  or  more  openings  in  the  skull  for  disinfection  and  drain- 
age. A  subdural  abscess  without  fracture  of  the  skull  is  to  be  accu- 
ratelj'  located  by  a  s3-stematic  and  accurate  stud}'  of  the  clinical  histor}' 
of  the  case,  and  bj-  reference  to  tlie  etiology  of  the  suppurative  process, 
and  the  information  thus  obtained  can  usualty  be  corroborated  by  focal 
s^-mptoms  which  point  to  the  exact  location  of  the  disease.  The  skull 
is  opened  with  the  chisel  over  the  point  where  the  abscess  is  suspected. 
If  the  dura  bulge  into  the  opening,  is  tense,  and  the  pulsations  of  the 
brain  cannot  be  felt,  the  surgeon  ma}'  be  almost  sure  that  a  subdural 
abscess  is  present,  and  confirms  his  suspicion  by  an  exploratory  punc- 
tui'e.  If  pus  is  found,  the  dura  mater  is  incised,  the  cavity  washed  out 
with  an  antiseptic  solution, and  a  tubular  drain  is  inserted.  A  daily 
change  of  the  dressing  and  washing  out  of  the  cavity  with  antiseptic 
solution  are  necessar}'  until  suppuration  lias  nearly  ceased  ;  then  the 
dressing  is  removed  less  frequentl}',  and  the  drain  is  shortened  as  the 
cavit}'  diminishes  in  size.  If  at  the  point  where  the  abscess  was  local- 
ized the  dura  present  no  indications  of  subdural,  intracranial  pressure, 
but  the  surgeon  feels  sure  otherwise  of  his  diagnosis,  it  is  justifiable  to 
make  a  number  of  small  exploratory  punctures  until  he  succeeds  in 
locating  the  suppurating  focus.  If  the  abscess-cavit}'  is  large,  and  the 
first  opening  has  been  made  at  a  point  UTifavorable  to  efficient  drainage, 
it  is  advisable  to  imitate  the  example  of  Macewan,  to  make  a  counter- 
opening  in  the  skull  and  dura  at  the  most  dependent  point,  and  to  main- 
tain through  draiuiige  until  suppuration  ceases.  A  localized  suppura- 
tive pachj'meningitis,  recognized  in  time,  and  located  with  sufficient 
accuracy  to  admit  of  radical  treatment  b}'  operative  measures,  is  an 
attection  which  the  modern  surgeon  treats  with  ever}^  assurance  of 
success. 

(b)  Suppurative  Leptomeningitis. — Inflammatiou  of  the  arachnoid, 
without  implication  of  the  pia  mater  and  surface  of  the  brain,  never 
occurs,  and  on  this  account  we  no  longer  speak  of  inflammation  of  au}' 
of  these  structures  as  separate  lesions,  but  substitute  the  term  lej^to- 
meningifis,  by  which  is  meant  inflammation  of  the  two  inner  envelopes 
of  the  bniin.  (•(tinbiiuMl  with  coiiic;!!  cneeijhalitis.  The  surface  of  the 
brain  is  su[)[)li('d  in  [)art  with   Itluod-vessels  from  tlie  pia  mater,  and  this 


268  PRINCIPLES   OF    SURGERY. 

intimate  vascular  connection  establishes  an  equally  intimate  pathological 
relationshi[)  between  these  two  structures.  A  septic  leptomeningitis  is 
a  diffuse  inflammation  of  the  arachnoid,  pia  mater,  and  cortex  of  the 
brain,  caused  by  infection  with  pus-microbes,  and  which,  in  the  absence 
of  all  tendencies  to  localization,  proves  fatal  before  well-marked  suppu- 
ration has  occurred.  Etiologically  and  pathologically  it  resembles 
diffuse  septic  peritonitis.  Examination  of  the  contents  of  the  skull 
reveals  great  vascularity,  more  or  less  serous  transudation,  and  softening 
of  the  gray  matter  of  the  brain.  Microscopical  examination  shows 
only  a  moderate  emigration  of  the  colorless  corpuscles  and  the  minute 
changes  in  the  capillar3'  vessels,  which  are  characteristic  of  acute  septic 
inflammation.  Suppurative  leptomeningitis  is  characterized  by  the 
presence  of  pus  between  and  upon  the  membranes  and  upon  the  surface 
of  the  brain.  Septic  leptomeningitis  alwa3's  terminates  in  suppuration, 
if  the  life  of  the  patient  is  sufficiently  prolonged  for  emigration  of  leuco- 
cj'tes  and  their  transformation  into  pus-corpuscles  to  occur.  Septic 
leptomeningitis  sometimes  appears  within  a  few  hours  after  a  perforating 
wound  of  the  skull.  Bergmann  relates  the  case  of  a  child  where  a 
convex  meningitis  could  be  diagnosticated  four  hours  after  an  injury 
of  the  skull.  Konig  reports  a  case  that  came  under  his  observation 
where  woll-mnrked  s^ymptoms  of  leptomeningitis  followed  ten  hours  after 
perforation  of  the  skull  with  the  point  of  a  sword.  The  wound  was 
examined  outside  of  the  hospital  with  instruments  that  had  not  been  dis- 
infected. Ten  hours  after  the  injury  the  patient  commenced  vomiting, 
and  had  a  temperature  of  39°  C.  The  following  day,  wild  delirium, 
strabismus  divergens,  and  a  temperature  of  40°  C.  The  second  day, 
coma,  rapid  pulse,  and  death.  The  necropsy  revealed  diffuse  septic 
leptomeningitis.  The  inflammatory  product  is  found  most  abundant  in 
the  subarachnoid  space.  The  effusion  in  this  space  is  sometimes  clear, 
raising  the  arachnoid  ;  it  contains,  also,  fibrin  in  flakes  and  membranes, 
or  it  presents  the  consistence  and  color  of  pus.  Pus  first  appears  along 
the  course  of  blood-vessels  in  the  pia  in  the  shape  of  yellow  streaks, 
which,  when  the}^  become  confluent,  tend  to  considerable  inflammatory 
thickening  of  the  membrane.  Pus  may  also  appear  in  the  ventricles  by 
wa}'  of  communication  with  the  subarachnoideal  spaces.  On  account  of 
the  absence  of  connective-tissue  spaces,  the  inflammation  of  the  surface 
of  the  brain  remains  superficial.  If  pus  form  here,  it  appears  as  small 
abscesses,  which  later  ma}'  become  confluent,  causing  superficial  destruc- 
tion of  the  brain-substance.  If  the  surface  of  the  brain  is  the  seat  of  a 
contusion,  sujipurative  encephalitis  is  more  diffuse,  and  ma}'  lead  to  a 
diffuse  acute  abscess  underneath  the  infected  envelopes. 

Besides  wounds  communicating  with  the  atmosphere  through  which 


ENDOCRANIAL    SUPPURATION.  269 

infection  takes  place,  suppurative  leptomeningitis,  like  pachymeningitis, 
can  be  caused  by  peripheral  suppurative  lesions,  as  phlegmonous  inflam- 
mation of  the  soft  tissues  covering  the  skull,  suppurative  osteomyelitis 
of  the  cranial  bones,  and  suppurative  inflammation  of  the  middle  ear. 
In  fractures  at  the  base  of  the  skull,  infection  frequentl}^  occurs  through 
a  ruptured  tympanum,  or  through  a  wound  of  the  soft  parts  in  the  naso- 
pharynx conimuuicating  directly  with  the  meninges. 

Symptoms  and  Diagnosis. — Tlie  surgeon  should  be  versed  in  the 
symptomatology  of  suppurative  leptomeningitis,  rather  for  the  purpose 
of  knowing  when  not  to  interfere,  by  operative  procedure,  in  cases  of 
endocranial  su})purative  lesions,  than  to  risk  his  reputation  in  a  fruitless 
attempt  in  operating  for  an  incurable  disease.  Diffuse  septic  and  suppu- 
rative leptomeningitis  are  fatal  diseases,  and  the  surgical  treatments  will 
in  all  probability  always  remain  of  a  purely  prophylactic  character. 
The  S3'mptoms  of  leptomeningitis  are  always  those  of  cortical  encepha- 
litis, from  which  it  cannot  be  distinguished  during  life.  The  disease  is 
often  initiated  by  a  chill,  like  phlegmonous  inflammation  in  other  locali- 
ties, followed  by  high  fever  and  other  sj-mptoms  of  septic  intoxication. 
In  other  cases  the  chill  is  absent  and  the  fever  develops  more  insidiously'. 
The  rise  of  temperature,  which  is  usuall}'  abrupt, — the  thermometer  after 
a  few  hours  shows  an  increase  to  39°  or  40°  C,  and  as  a  rule  presents 
but  slight  variations, — is  caused  by  the  absorption  of  septic  material 
from  the  infected  and  inflamed  tissues.  The  intra-cranial  pressure  and 
fever  give  rise  at  once  to  symptoms  which  indicate  the  presence  of  cere- 
bral irritation.  Headache,  morbid  sensitiveness  to  external  impressions, 
sleeplessness,  restlessness,  and  psychical  perturbation  are  some  of  the 
most  constant  and  conspicuous  early  S3anptoms.  If  the  patient  fall 
into  a  short  nap  he  starts  up  suddenl}^  and  behaves  like  a  maniac.  The 
pupils  are  usuall}^  contracted  at  first,  but  dilate  as  other  symptoms  of 
compression  appear.  Often  they  are  unequal  in  size  and  respond  only 
shiggishl}'  to  light.  Localized  general  convulsions  frequently  attend 
the  stage  of  irritation.  Vomiting  and  constipation  are  among  the  early 
symptoms.  Paralysis  of  definite  muscular  groups,  according  to  Berg- 
mann,  indicates  extension  of  the  disease  to  the  region  of  motor  centres. 
The  face  is  suff'tised,  the  conjunctivae  injected,  and  the  pulsations  of  the 
carotid  arteries  increased.  The  pulse,  at  first  increased  in  frequencj', 
bounding  and  firm,  becomes  slower  as  cerebral  compression  advances. 
If,  after  its  frequenc}'  has  been  reduced  to  40  or  50  beats  per  minute,  it 
again  becomes  rapid,  it  is  a  sure  indication  of  approaching  death. 

If  the  disease  develop  in  the  course  of  a  perforating  wound  of  the 
skull,  the  increased  intra-cranial  pressure  is  manifested  by  bulging  of 
the  dura  mater  into  the  wound,  or  if  the  envelopes  of  the  brain   have 


270  PRINCIPLES   OK    SURGERY. 

been  lacenited,  by  hernia  of  the  biiiui.  Tlie  prohipsed  portion  of  the 
brain  often  sloughs,  when  putrefaction  of  tlie  dead  tissue  occurs  as  an 
unavoidable  result,  and  death  from  sepsis  is  hastened  b}^  such  an  occur- 
rence. Bergniann  has  recently  called  the  attention  of  the  profession  to 
the  fact  that  leptomeningitis,  affecting  the  convex  surface  of  the  brain, 
leads  at  once  to  paralj'sis  of  one  extremity,  or  hemiplegia,  by  the  exten- 
sion of  the  disease  to  motor  centres.  Indications  pointing  to  localized 
symptoms  of  central  irritation  can  l)e  explained  by  the  same  theory. 
Leptomeningitis  at  the  base  of  the  ])rain  is  not  attended  b}'  any  definite 
localized  focal  symptoms,  and  the  retraction  of  the  head  takes  place  in 
consequence  of  the  extension  of  the  inflammation  to  the  meninges  of 
the  spinal  cord.  Basilar  meningitis  in  its  advanced  stage  gives  rise  to 
a  peculiar  disturbance  of  respiration, — the  Cheyne-Stokes  phenomenon. 
With  the  appearance  of  compression  of  the  brain  the  symptoms  of  cen- 
tral irritation  subside  and  give  place  to  the  paralytic  stage.  The  patient 
passes  from  a  condition  of  listlessness  gradually  into  a  stupor,  and 
finall}'  into  complete  coma.  With  the  appearance  of  monoplegia  and 
hemiplegia  some  centres  may  be  still  in  a  condition  of  irritation,  so  that 
symptoms  of  irritation  and  paralysis  may  be  manifested  at  the  same 
time.  During  the  paralytic  stage  the  suffusion  of  the  face  disappears, 
the  face  is  pallid,  and  the  whole  surface  of  the  bodj-  covered  with  a 
clammy,  cold  perspiration  ;  the  pupils  dilate  and  no  longer  respond  to 
light ;  the  pulse  becomes  small  and  rapid,  and  death  is  preceded  bj'" 
relaxation  of  all  sphincter  muscles. 

Treatment. — The  proph^dactic  treatment  has  for  its  object  the  pre- 
vention of  infection  through  wounds  communicating  with  the  contents 
of  the  skull.  Rigid  antiseptic  treatment  of  all  compound  fractures  of 
the  skull  must  be  carried  out  in  the  most  pedantic  manner.  Fractures 
of  the  base  of  the  skull,  communicating  with  the  atmospheric  air  through 
a  ruptured  tympanum  or  through  a  lacerated  wound  in  the  naso-pharyn- 
geal  region,  should  be  treated  upon  the  same  principles  as  a  compound 
fracture  of  the  vault  of  the  cranium.  If  the  tympanum  has  been  rup- 
tured the  external  meatus  is  thoroughly  disinfected  and  packed  loosely 
with  iodoform  gauze,  over  which  a  filter  of  salicylated  cotton  is  applied. 
If  the  fracture  communicate  with  a  wound  of  the  naso-phar^'ngeal 
region,  disinfection  is  aimed  at  by  using  an  antiseptic  nasal  douche  and 
plugging  the  posterior  nares  with  tampons  of  iodoform  gauze,  which  are 
to  be  removed  daily,  and,  after  using  the  nasal  douche,  are  to  be  replaced 
by  new  ones.  The  prophylactic  treatment  of  leptomeningitis,  caused  by 
suppurating  foci  in  the  coverings  of  the  skull,  the  internal  ear,  or  in  the 
cranial  bones,  can  be  carried  out  most  successfully  by  early  and  rational 
treatment  of  the  primary  diseases.     With   the   first  appearance  of  the 


BRAIN-ABSCESS.  271 

sj'mptoms  of  leptomeningitis,  the  surgeon  should  lose  no  time  in  render- 
ing the  wound  or  primary  suppurating  depot  aseptic  by  operative 
measures,  combined  with  most  rigid  antiseptic  precautions,  with  a  faint 
hope  that  such  measures  maj',  in  exceptional  cases  at  least,  lead  to  a 
successful  issue  by  limiting  the  extension  of  the  infection.  As  soon  as 
the  disease  has  become  diffuse  the  prospects  of  a  favorable  termination 
are  almost  nil.  It  may  be  possible  that  multiple  openings  in  the  skull, 
with  subaracluioid  drainage  and  frequent  antiseptie  irrigations  or  per- 
manent irrigation,  will  in  the  future  become  an  established  and  feasible 
method  of  treatment  in  such  cases.  From  a  surgical  stand-point  such 
heroic  treatment  appears  the  only  rational  course  to  pursue  in  a  class  of 
patients  otherwise  doomed  to  certain  death.  The  multiple  perforations 
would  have  a  potent  influence  in  diminishing  the  intra-cranial  pressure, 
and  drainage,  combined  with  frequent  or  permanent  irrigation,  might,  at 
least  in  a  small  percentage  of  cases,  succeed  in  sterilizing  the  extensive 
area  of  infection. 

BRAIN-ABSCESS. 

The  term  abscess  of  the  brain  should  be  limited  to  circumscribed 
collections  of  pus  surrounded  on  all  sides  by  brain-tissue.  Suppuration 
occurring  between  the  brain  and  its  envelopes,  from  a  circumscribed 
suppurative  leptomeningitis,  is  not  a  brain-abscess,  A  brain-abscess  is 
the  result  of  a  circumscribed  suppurative  encephalitis.  The  acute  form 
occurs  when  a  contused  portion  of  the  brain  becomes  infected  through 
a  wound  communicating  with  the  atmospheric  air,  but,  as  this  form  will 
seldom,  if  ever,  become  the  subject  of  successful  operative  treatment, 
our  remarks  will  apply  to  abscess  of  the  brain  proper,  or  chronic  abscess. 
A  chronic  circumscribed  encephalitis  may  originate  in  a  contused  area 
of  the  brain,  without  any  external  wound  or  direct  route  of  infection, 
from  localization  of  pus-microbes  in  the  locus  mmoris  resistentiae.  Such 
cases  have  been  frequently  observed  where,  weeks  and  months  after  the 
subsidence  of  the  symptoms  resulting  from  the  immediate  effects  of  a 
head  injury,  remote  s^-mptoms  pointed  to  a  central  suppurating  focus  in 
the  brain.  The  occurrence  of  such  grave  remote  consequences  renders 
the  prognosis,  even  after  slight  injuries  to  the  skull,  always  more  or  less 
doubtful.  In  other  instances  an  abscess  forms  around  a  foreign  body 
that  has  lodged  in  the  brain,  and  has  remained  for  a  long  time  without 
having  given  rise  to  any  local  or  general  disturbance.  Infected  pene- 
trating wounds  of  the  skull  may  heal,  and  the  patient  apparently  recover 
perfect  health,  when  at  some  remote  time,  and  in  direct  causal  connec- 
tion with  the  previous  infection,  a  chronic  abscess  develops,  perhaps, 
some  distance  from  the  primary  seat  of  infection.  Most  frequently  such 
abscesses  ai'e  caused  b}'  suppurative  inflammation  of  the  internal  ear, 


27*2  PRINCIPLES   OF    SURGERY. 

:ind  suppurative  osteomyelitis  of  the  cranial  bones.  In  size  they  vary 
from  that  of  a  pea  to  that  of  an  entire  hemisphere.  They  ma}'  remain 
stationary  for  twenty  years,  but  the  period  of  latency  may  pass  into 
activity  at  any  time.  A  large  abscess  in  the  white  substance  of  a  hemi- 
sphere may  give  rise  to  no  functional  disturbances  wiiatever,  and  can 
only  be  recognized  by  the  terminal  S3'mptoms.  In  other  cases  the  abscess 
can  not  only  be  diagnosticated  during  life,  but  its  location  accurately 
determined  by  symptoms  which  point  to  destruction  of  a  particular 
part  of  the  brain. 

Symptoms  and  Diagnosis. — The  first  symptoms  are  insidious  in  their 
onset,  and  often  of  a  very  indefinite  nature.  The  first  thing  noticed  is, 
frequently,  a  hypersensitiveness  and  irritable  temper  of  the  patient, 
with  more  or  less  severe  headache.  Early  loss  of  memory  is  often 
noticed,  and  the  patient  becomes  dull,  sullen,  unconcerned,  and  reckless 
in  his  business  transactions.  If  the  abscess  involve  any  of  the  motor 
centres,  or  a  considei-able  portion  of  fibres  originating  from  them,  mono- 
spasm or  hemispasm,  or  monoplegia  or  hemiplegia  follow  as  peripheral 
evidences  of  the  central  lesion.  General  convulsions,  Avhich  sometimes 
occur  at  this  stage,  have  less  diagnostic  value  than  localized  focal  symp- 
toms. Abscess  of  the  brain  seldom  causes  fever;  on  the  other  hand,  the 
temperature  is  often  subnormal.  A  sudden  rise  in  temperature  indicates 
that  the  abscess  has  reached  the  surface  of  the  brain,  and  that  a  terminal 
leptomeningitis  has  developed.  Rupture  of  an  abscess  into  one  of  the 
ventricles  is  followed  by  general  convulsions,  paral^'sis,  and  death. 
Prominence  of  the  dura  over  the  abscess  and  absence  or  diminution  of 
cerebral  pulsation  are  important  diagnostic  signs,  especiall}'  in  cases 
where  the  abscess  is  located  near  the  surface  of  the  brain.  Examination 
of  the  exposed  brain  by  palpation  may  elicit  evidences  of  deep-seated 
fluctuation.  In  exceptional  cases  the  portion  of  brain  covering  the 
abscess  is  firmer  than  normal  from  inflammatory  infiltration  (Rose). 

Gussenbauer  states  that  in  some  cases  the  presence  of  the  abscess 
can  be  ascertained  by  the  existence  of  fluctuation. 

Prognosis. — An  abscess  in  the  brain  is  always  an  imminent  source 
of  danger  to  life.  A  considerable  nccumulation  of  pus  in  the  brain,  like 
in  any  other  organ,  is  never  removed  by  absorption.  If  the  abscess 
remain  in  the  active  stage  it  gradually  increases  in  size  until  it  ruptures 
into  one  of  the  ventricles  or  reaches  the  surface  of  the  brain,  in  either 
event  resulting  in  complications  which  lead  to  a  rapidly-  fatal  termination. 
It  may  remain  in  a  latent  condition  for  an  indefinite  period  of  time,  but 
the  life  of  the  patient  is  alwa3'S  in  jeopardy,  as  acute  exacerbations  may 
come  on  at  any  time.  If  an  abscess  form  after  a  perforating  injury  of 
the  skull,  and  the  pus  finds  an  exit  through  a  permanent  fistulous  open- 


BRAIN-ABSCESS.  273 

ing,  the  general  lieulth  may  remain  sufficiently  good  to  enable  the  patient 
to  follow  his  occupation.  A  ease  came  recently'  under  my  observation 
where  I  could  introduce  the  probe  to  a  distance  of  four  inches  into  the 
brain,  and  ^-et  the  general  health  remained  unimi)aired,  although  this 
condition  had  existed  for  years.  Tiie  brain-abscess  in  this  case  deA'el- 
oped  in  connection  with  purulent  intlammation  of  the  middle  ear.  I 
have  knowledge  of  another  ease,  where  a  young  man  received  a  perfo- 
rating wound  of  the  skull,  which  was  followed  by  tlie  formation  of  an 
abscess  of  the  brain  that  discharged  externally.  The  patient  filled,  in 
a  creditable  manner,  a  responsible  and  important  government  position 
for  thirty  3'ears,  and  died  from  another  cause. 

The  necrops}'  showed  an  abscess-cavity  the  size  of  an  orange, 
located  in  the  anterior  right  lobe  of  the  brain,  which  communicated  with 
the  external  surface  through  a  fistulous  opening  in  the  skull.  A  few 
cases  are  reported  where  recovery  followed  the  spontaneous  discharge 
of  the  contents  of  the  abscess  through  the  ear  or  nose,  but  ordinarily 
such  an  occurrence  is  followed  by  putrefiiction  of  the  remaining  contents 
of  the  abscess-cavitv  and  death  from  sepsis. 

Treatment. — All  eflorts  to  cure  an  abscess  of  the  Itrain  b}'  external 
applications,  or  internal  medication,  will  be  worse  than  useless  in  effect- 
ing removal  of  the  i)us  b^'  absorption.  All  expectant  treatment  is  worse 
than  useless.  Brain-abscess  must  be  treated  on  the  same  principles  as 
abscess  in  any  other  organ,  by  incision  and  drainage.  The  great  difficulty 
in  these  cases  is  to  make  a  sufficiently  accurate  diagnosis  in  regard  to 
the  exact  location  of  the  abscess.  Before  an3thing  was  known  in  refer- 
ence to  tlie  subject  of  cerebral  localization,  Dupu^'tren  plunged  a  bistoury 
deeplj'  into  the  brain,  and  was  fortunate  enough  to  hit  an  abscess  which 
he  suspected,  and  his  patient  recovered.  The  same  bold  treatment  has 
been  frequently  followed  since,  but  not  with  the  same  brilliant  result,  as, 
in  the  majority-  of  cases,  either  no  abscess  existed  or  the  incision  was 
made,  not  into,  but  aside  of,  the  abscess.  Renz  cnred  an  abscess  of  the 
brain  b}'  repeated  aspirations  through  a  fissure  in  the  skull.  The  average 
surgeon,  at  the  present  time,  would  not  undertake  to  incise  a  brain  for 
abscess  unless  he  had  previously  located  the  abscess  bj^  a  careful  stud}' 
of  focal  symptoms,  and  b}'  a  resort  to  exploratory  punctures.  Bergmann 
condemns  the  nse  of  the  exploring-sj-ringe  for  this  purpose,  but  in  the 
hands  of  those  less  skilled  in  cerebral  localization  than  this  eminent 
surgeon  the  exploring-needle  will  alwaj's  be  regarded  as  a  welcome  and 
useful  instrument  of  exact  diagnosis. 

Cerebral  Localization. — As  the  peripheral  symptoms  upon  which  the 
surgeon  relies  in  locating  an  abscess  in  the  brain  are  caused  b}' irritation 
or  destruction  of  the  motor  tracts  or  centres,  it  is  absolutely  necessary 


274 


PRINCIPLES   OF   SURGERY. 


for  him  to  become  familiar  with  the  topography  of  the  motor  centres. 
A.  W.  Hare  gives  a  very  practical  instruction  on  cerebral  localization  in 
a  paper  published  in  tlie  London  Lancet^  March  3,  1888,  from  which  I 
will  quote  below: — 

"  In  the  parietal  region,  grouped  around  the  fissure  of  Rolando,  are 
the  areas  associated  with  movements  of  the  extremities  of  the  opposite 
side  of  the  body,  and,  at  the  lower  end  of  the  fissure,  those  related  to 
movements  of  the  mouth  and  tongue.  In  the  accompanying  diagram 
(Fig.  62)  the  motor  areas  have  been  mnrketl  in  their  anatomical  relations 
to  the  other  structures  of  a  normal  head,  dissected  for  the  purpose,  show- 
ing the  brain  in  its  natural  position.  The  areas  associated  with  move- 
ments in  neighboring  regions  of  the  body  have  been  shaded  alike  in  the 
figure.     Thus,  the  areas  A,  B,  C,  and  D,  bounding  the  fissure  of  Rolando 


Fig.  62.— Motor  Areas. 


posteriorly,  and  5  and  6,  in  front  of  the  fissure,  together  with  2,  3,  and 
4,  at  its  upper  end,  are  those  in  functional  connection  with  the  upper 
extremity;  A,  B,  C,  and  D  being  concerned  in  the  movements  of  the 
fingers,  head,  and  wrist,  5  in  a  forward  movement  of  the  arm,  6  in  pro- 
nation and  supination  of  the  forearm,  and  2,  3,  and  4  in  co-ordinated 
movements  of  the  whole  upper  extremity'.  The  areas  7,  8,  9,  10,  and  11, 
indicated  as  having  a  common  region  of  motor  representation,  are  re- 
lated to  movements  of  the  tongue  and  of  the  muscles  around  the  mouth. 
Area  1  represents  in  part  movements  of  the  lower  extremity.  In  the 
same  way  areas  of  representation  of  general  and  of  special  sensation  are 
located  by  Terrier  around  the  horizontal  limb  of  the  fissure  of  S3'lvius. 
It  must  not  be  overlooked  that  this  mapping  out  of  areas  has  an  absolute 
exactitude  onl}'  in  the  case  of  the  species  of  ape  upon  which  the  experi- 
ments were  performed.     Its  bearing  in  the  human  subject  is  one  of  great 


BRAIN-ABSCESS.  275 

relative  importance,  but  it  must  not  be  louivcd  upon  as  a  final  statement 
of  fact,  in  the  case  of  man,  until  each  area  can  be  shown  to  be  correctly 
placed,  as  it  is  b}'  the  accumulation  of  a  sufficient  number  of  clinical  and 
of  post-mortem  observations  directly  confirming  the  method  employed. 

"In  the  stud}'  of  cranio-cerebral  topography  the  surgeon  has  to  rely 
on  four  primarj'  landmarks  in  establishing  a  system  of  measurements. 
These  are  the  glabella,  or  root  of  the  nose,  which  bears  a  definite  relation 
to  the  anterior  limit  of  the  cranial  cavity,  and  the  occipital  protuberance, 
or  inion,  which  bears  a  similar  relation  to  its  posterior  end,  correspond- 
ing to  the  junction  of  the  falx  with  the  tentorium.  The  whole  mass  of 
the  cerebrum  is  disposed  between  these  two  points,  and  the}'  bear  definite 
relations  to  its  cortical  matter,  uninfluenced  by  the  structure  and  contour 
of  the  bones  forming  the  vault.  The  third  constant  landmark  is  the 
external  angular  process  of  the  frontal  bone,  which  bears  a  relation  to 
the  lateral  expansion  of  the  frontal  lobes,  similar  to  that  borne  hy  the 
two  prominences  already  mentioned,  to  the  anterior  and  posterior  ex- 
tremities of  the  cerebrum.  It  has  also  a  uniform  relation  to  the  fissure 
of  Sylvius.  Lastl}',  the  parietal  eminence  is  of  value,  since  it  marks  tlie 
greatest  lateral  expansion  of  the  substance  of  the  hemisphere,  and,  as 
Turner  has  shown,  bears  a  special  relation  to  the  submarginal  convolu- 
tion. To  find  the  upper  end  of  the  fissure  of  Rolando  by  the  use  of 
these  data,  the  surface  measurement  in  the  middle  line  of  the  head  should 
be  taken  over  the  scalp  from  the  glabella  to  the  occipital  protuberance. 
In  ordinar}-  adult  heads  this  will  var}-  from  11  to  13  inches;  measured 
along  this  line  from  before  backward,  the  distance  from  the  glabella  to 
the  top  of  the  fissure  will  be  55.7  per  cent,  of  the  total  distance  from  the 
glabella  to  the  occipital  protuberance.  The  following  scale  shows  the 
distance  from  the  glabella  to  the  top  of  the  fissure  in  all  ordinar}'- 
heads : — 

When  the  distance  from  the  glabella  to  the  The  distance  from  the  glabella  to  the  upper 

occipital  protuberance  is  end  of  the  fissure  of  Rolando  is 

11  inches,  6^  inches. 

iij    "  el      " 

12  "  6|        " 
12^     "  7  " 

13  "  7J 

"  To  find  the  top  of  the  Rolandic  fissui'c,  Thane  halves  the  distance 
fiom  the  glabella  to  the  occipital  protuberance,  and,  having  thus  de- 
fined the  middle  point  of  the  vertex,  takes  a  point  half  an  inch  behind  it  as 
the  location  of  the  upper  end  of  the  fissure.  Having  thus  ascertained 
the  upper  end  of  the  fissure,  it  is  desirable  to  determine  its  length 
and  direction.     The  scalp  measurement  corresponding  to  its  length  is 


2T6 


PRINCIPLES   OF    SURGERY. 


3|  inches.  It  runs  from  above  downward  and  forward,  its  axis  making 
an  angle  of  67  degrees  with  tlie  middle  line. 

"  Wilson's  cyrtometer  is  an  exceedingly  useful  aid  in  locating  the 
fissure  of  Rolando.  It  consists  of  three  strips  of  flexible  metal  and  a  tape 
for  securing  it  in  situ.  The  method  of  its  application  is  illustrated  by 
Fig.  64. 

"  The  broadest,  transverse  strip  passes  coronally  around  the  forehead, 
corresponding  with  the  glabella  and  external  angular  process ;  the 
narrower,  longitudinal  strip  passes  backward  from  the  glabella  in  the 
middle  line  to  the  occiput.     This  strip  is  marked  with  two  scales  of 

R 


Fig.  63.— Wilson's  Cyrtometer. 


Fig.  64 —Wilson's  Cyrtom- 
eter Applied. 

G.  glabella ;  E  A  P,  external  angular 
process :  R,  fissure  of  Rolando,  its  posi- 
tion and  direction  marked  by  the  lateral 
strip  of  metal. 


letters, — capitals  in  its  posterior  fourth,  and  small  letters  about  the 
middle  of  the  strip.  These  two  scales  bear  a  relation  to  one  another, 
calculated  to  aid  in  the  application  of  the  instrument  to  an  ordinary 
head.  Measured  from  the  glabella  backward,  the  distance  to  any 
given  small  letter  is  55.7  per  cent,  of  tlie  distance  from  the  glabella  to 
the  corresponding  capital  letter;  thus,  when  any  capital  letter  will  co- 
incide with  the  top  of  the  fissure,  a  third  narrow,  reversible  strip  strikes 
on  the  longitudinal  strip  of  metal,  marking  an  angle  of  67  degrees,  opening 
forward  and  marked  at  3f  inches  from  its  attached  end,  thus  giving  the 
length  and  direction  of  the  fissure  on  the  surface  of  the  head.  To  de- 
termine the  exact  location  and  direction  of  the  fissure,  a  line  is  drawn 


BRAIN-ABSCESS. 


271 


from  the  external  angular  process  of  the  frontal  bone  backward  to  the 
occipital  protuberance,  taking  the  shortest  route  between  these  points. 
Such  a  line  drops  a  little  toAvard  the  external  auditory  meatus,  avoiding 
the  greater  convexit}'  of  the  skull,  which  lies  in  the  course  of  a  hori- 
zontal line  between  the  bou}-  prominences.  It  usually  passes  about  i 
inch  above  the  meatus,  and  thus  closely  corresponds  to  the  floor  of  the 
middle  fossa,  and  behind  runs  parallel  to  and  nearly  in  the  same  course 
with  the  attachment  of  the  tentorium  and  the  posterior  half  of  the 
lateral  sinus.     A  measurement  of  1|  inches  along  this  line,  backward 


POF. 


O.P. 


Fig.  65.— Head,  Sktill,  and  Cerebral  Fissures.    {Adapted  from  Marshall.) 

O  p.  occipital  protuberance ;  E  A  P,  extern.al  anpilar  process ;  S  F,  Sylvian  fissure  :  A,  its  ascending 
limb;  F  R.  fissure  of  Rolando;  P  E,  parietal  eminence  ;  M  M  A,  middle  meningeal  artery  T  S,  tip  of 
temporo-sphenoidal  lobe ;  B,  Broca's  convolution. 

from  the  external  angular  process,  marks  the  lower  end  of  the  fissure 
of  Sylvius.  From  this  point  a  straight  line  drawn  to  the  centre 
of  the  parietal  eminence  accuratel}"  marks  the  course  of  the  posterior 
limb  of  tlie  fissure.  The  main  line  of  the  fissure  follows  the  line  of  the 
squamo-parielal  suture  to  its  highest  point,  whence  it  continues  its  course 
to  tlie  parietal  eminence.  The  middle  meningeal  arter}',  after  grooving 
the  inner  surface  of  the  great  wing  of  the  sphenoid,  passes  on  to  the  ante- 
rior angle  of  the  parietal  bone,  and  is  distributed  to  the  dura  mater  lining 
the  anterior  and  superior  half  of  the  bone.  If  the  surgeon  desire  to  ex- 
pose the  tip  of  the  temporo-sphenoidal  lobe,  he  should  open  the  skull 


278  PRINCIPLES   OF    SURGERY. 

behind  the  upper  extreniit}'  of  the  great  wing  of  the  sphenoid  ;  if  to  expose 
Broca's  convolution,  immediately  in  front  of  the  same  bony  peninsula. 
The  sites  of  the  two  operations  are  shown  in  Fig.  65." 

Opening  of  the  Skull. — The  operative  treatment  of  abscess  of  the 
brain  i)resupposes  an  accurate  diagnosis  by  means  of  cerebral  localiza- 
tion and  a  careful  study  of  the  clinical  and  etiological  aspects  of  the 
case.  If  symptoms  of  abscess  of  the  brain  arise,  after  a  compound  frac- 
ture of  the  skull,  before  the  continuity  of  the  skull  has  been  restored, 
exploration  can  be  done  with  a  fine  needle  through  a  fissure,  or  at 
some  point  where  fragments  have  been  removed ;  and,  if  pus  is  found,  a 
closed  hemostatic  forceps  can  be  pushed  along  the  side  of  the  needle 
into  the  abscess,  and  the  track  enlarged  by  separating  the  blades  before 
withdrawing  the  instruments.  Into  this  track  a  drainage-tube  is  intro- 
duced, the  abscess-cavity  gently  irrigated,  and  the  wound  disinfected  and 
dressed  antisepticall}' ;  or,  a  small  qnantit}'  of  peroxide  of  hydrogen 
can  be  injected  into  the  abscess-cavity  through  the  drainage-tube,  which 
will  not  only  force  out  the  contents,  but  will  also  sterilize  the  walls  of 
the  abscess  more  thoroughly  than  an}'  other  antiseptic.  If  an  abscess 
develop  in  the  brain  in  an  intact  skull,  or  after  the  fracture  has  healed, 
the  skull  must  be  opened  at  a  point  immediately  over  the  abscess.  By 
means  of  the  measurements  given,  or  by  the  use  of  Wilson's  cyrtometer, 
the  motor  centre  or  centres  affected  by  the  abscess  are  marked  upon  the 
shaved  and  disinfected  scalp  before  the  skull  is  exposed ;  and  the  exact 
location  of  the  abscess  is  also  marked  on  the  skull  by  making  a  puncture 
through  the  scalp  with  a  small  perforator,  so  that  the  location  can  be 
recognized  after  the  soft  parts  have  been  reflected.  The  bone  is  laid 
bare  at  this  point  by  Horslej^'s  flap,  which  is  made  by  ahorse-shoe-shaped 
incision,  the  convexity  of  which  is  directed  upward.  The  flap,  with  the 
periosteum  attached,  is  turned  downward.  After  all  hemorrhage  has 
been  arrested  the  skull  is  opened,  either  by  using  a  large  trephine  or, 
"what  is  better,  with  a  chisel ;  the  button  of  bone  or  bone-chips  are  trans- 
ferred into  a  warm  antiseptic  solution,  where  the}'  are  kept  until  needed 
for  re-implantation ,  should  this  be  deemed  necessar}^  or  advisable.  If  the 
dura  mater  is  tense  and  bulge  into  the  opening,  and  cerebral  pulsations 
are  feeble  and  entirely  wanting,  the  indications  are  that  the  skull  has 
been  opened  near  or  directl}'  over  the  abscess.  The  opening  need  not  be 
larger  than  an  inch  in  diameter. 

Methodical  Exploration  of  the  Brain. — Experiments  and  clinical 
experience  have  shown  that  the  brain  can  be  explored  in  diflTerent  direc- 
tions with  a  fine,  hollow,  aseptic  needle  without  an}'  immediate  or  remote 
bad  eflfects.  Tlie  brain  should  never  be  incised  for  abscess  until  the 
abscess    has   been   located    by   methodical   exploration.     An    ordinary 


BRAIN-ABSCESS.  279 

exploring-syringe  with  a  delicate  needle  about  4  inches  in  length 
should  be  used  for  this  purpose.  The  needle  is  pushed  into  the  brain  in 
the  direction  in  which  tlie  abscess  is  suspected,  and  to  the  necessar}^ 
depth,  when  aspiration  is  made  and  the  result  carefull}'  noted.  If  no 
pus  is  found  the  needle  is  withdrawn  or  pushed  forward  in  the  same 
direction,  and  aspiration  made  at  different  points  in  its  track  ;  and,  if  no 
pus  is  found  in  that  direction,  it  is  withdrawn  and  pushed  in  another 
direction,  and  the  same  manoeuvres  repeated.  In  this  manner  a  large 
territory  can  be  explored  and  even  very  small  abscesses  located.  When 
the  abscess  has  been  located  by  this  method  of  exploration,  the  needle  is 
used  as  a  guide  for  a  small  pair  of  haemostatic  forceps,  which  is  pushed 
forward  along  its  side  until  the  abscess  has  been  reached,  when  it  is 
unlocked,  the  blades  slightly  separated,  and  as  the  instrument  is  with- 
drawn the  track  is  sufficientl\"  enlarged  to  permit  the  insertion  of  a 
rubber  drain  the  size  of  an  ordinar}'  lead-pencil.  The  needle  is  only 
removed  after  the  drain  is  in  situ.  Fenger,  of  Chicago,  has  written  an 
exceedingh'  Aaluable  paper  on  exploration  of  the  brain,  in  the  diagnosis 
and  treatment  of  abscess  of  the  brain,  in  which  he  has  furnished  abundant 
proof  both  of  the  harmlessness  and  utilit}'  of  this  procedure. 

After  the  abscess  has  been  opened  and  drained,  it  is  advisable  to 
wash  it  out  gentl}'  with  some  non-irritating  and  yet  effective  antiseptic 
solution,  either  with  half  of  a  1-per-cent.  solution  of  acetate  of -aluminum 
or  a  2-per-cent.  solution  of  boracic  acid,  or  it  is  injected  with  peroxide 
of  hjdrogen.  As  the  abscess-walls  are  never  firm,  everj^  precaution  must 
be  taken  to  prevent  overdistention,  but  gentle  irrigation  is  continued 
until  the  fluid  returns  clear.  If  the  skull  has  been  opened  by  removing  a 
disk  of  bone  by  trephining,  an  opening  in  this  must  be  made  at  its  lower 
margin,  which  will  permit  bringing  the  drainage-tube  out  to  the  external 
surface  after  implantation.  If  bone-chips  are  re-implanted,  a  space 
for  the  drain  must  be  left  in  the  most  dependent  portion  of  the  opening. 
The  drainage-tube  is  brought  out  at  one  of  the  lower  angles  of  the  wound 
or  through  a  button-hole  in  the  flap.  The  flap  is  secured  in  its  position 
by  a  requisite  number  of  sutures.  Daily  changes  of  dressing  is  required 
until  suppuration  diminishes,  when  the  drain  is  shortened  from  time  to 
time  and  the  dressing  changed  less  frequently.  The  drainage-tube  is  not 
to  be  removed  until  the  abscess-cavity  is  closed,  as  otherwise  a  relapse 
would  be  liable  to  occur  which  would  require  a  repetition  of  the  first 
operation.  The  most  unsatisfactory  aspect  of  the  surgical  treatment  of 
abscess  of  the  brain  is  tlie  fact  that  in  some  instances  multiple  abscesses 
are  present, — an  occurrence  which  is  be3'ond  the  limits  of  the  present 
means  of  diagnosis.  In  such  cases  the  surgeon  maj'  cure  one  abscess, 
but  the  patient  succumbs  from  the  effect  of  those  that  have  not  been 


280  PRINCIPLKS    OF    SURGERY. 

discovered.  Tlie  appearance  ol"  a  hernia  cerebri,  after  the  evacuation 
and  drainage  of  an  abscess  of  tiie  brain,  is  a  condition  wliich  points  to 
tlie  existence  of  an  additional  abscess  or  abscesses.  Should  such  a 
condition  appear  during  the  after-treatment  of  an  abscess  of  the  brain, 
treated  by  evacuation  and  drainage,  it  would  furnish  a  strong  temptation 
to  resort  to  another  methodical  exploration  with  a  view  of  subjecting 
additional  abscesses  to  the  same  radical  treatment.  Should  the  first 
opening  into  an  abscess  of  the  brain  not  be  suitable  for  eifective  drainage, 
it  would  be  well  to  follow  the  example  of  Macewan  and  open  the  skull 
at  a  lower  point,  tunnel  the  intervening  portion  of  the  brain,  between 
this  opening  and  the  abscess  cavity',  with  haemostatic  forceps,  and  thus 
establish  an  additional  and  more  efficient  route  for  drainage.  In  the 
surgical  ti'eatment  of  abscess  following  suppurative  inflammation  of  the 
middle  ear,  it  is  well  to  remember  that  in  these  cases  the  abscess  is 
usually  located  in  the  vicinity  of  the  petrous  portion  of  the  temporal 
bone,  and  that  in  exploring  the  ])rain  the  needle  should  be  inserted  in 
this  direction. 

EMPYEMA. 

Emp3'^ema  is  a  collection  of  pus  in  the  pleural  cavit}'.  It  is  always 
the  result  of  a  suppurative  pleuritis. 

Bacteriological  Studies. — A  penetrating  wound  of  the  pleural  cavity 
is  more  frecpiently  followed  by  infection  with  pus-microbes  and  suppura- 
tive pleuritis  than  perforation  of  one  of  the  bronciiial  tubes,  as  in  the 
latter  accident  the  atmospheric  air  entering  the  pleural  cavity  has  under- 
g6ne  a  process  of  filti'ation  during  its  passage  through  the  respiratory 
tract.  Suppurative  pleuritis,  occurring  without  direct  infection  through 
a  perforation  in  the  thoracic  wall  or  one  of  the  bronchial  tubes,  is  always 
caused  by  localization  of  pus-microbes  within  or  upon  the  serous  mem- 
brane lining  the  pleural  cavit3\  Localization  of  pus-microbes  occurs  in 
the  pleura  or  pleural  cavity,  either  as  a  primar}'  or  secondar}'  infection. 
Frankel  made  a  bacteriological  study  of  12  cases  of  emp3'ema.  In 
3  cases,  in  which  no  special  cause  could  be  traced,  the  pus  contained 
exclusively  the  strejjtococcus  pyogenes.  In  3  cases  the  pus  contained 
only  pneumococci.  Other  authors  have  found  in  such  cases  also  other 
l)Us-microbes.  Friinkel  believes  that  when  this  is  the  case  they  have 
localized  in  consequence  of  a  secondar}'  invasion.  The  presence  of 
streptococci  in  the  pus  from  a  suppurating  pleural  cavity  presents  noth- 
ing characteristic,  as  the  microbe  is  also  found  in  cases  in  which  the 
emp3^ema  is  secondary  to  pneumonia  and  tuberculosis.  On  the  other 
hand,  he  assigns  to  the  pneumococcus,  in  pus  taken  from  a  pleural  cavity, 
a  diagnostic  significance,  as  it  proves,  beyond  all  doubt,  that  the  suppu- 
rative pleuritis  occurred  in  the  course  of  a  pneumonia  as  a  secondary 


EMPYEMA.  281 

affection;  consequently,  its  presence  in  the  pus  is  positive  proof  that  a 
pneumonia  exists  or  has  existed,  even  if  the  clinical  and  physical  symp- 
toms were  not  sufficiently^  clear  to  indicate  its  existence.  In  4  cases 
the  empyema  had  a  tuberculous  origin,  in  2  of  which  pneumothorax 
was  present  at  the  same  time.  The  presence  of  the  bacillus  of  tubercu- 
losis in  the  pus  is  not  easih' demonstrated,  but  the  absence  of  this 
microbe  is  no  sign  that  the  disease  is  not  tubercuhu',  tis  inoculations 
with  pus  in  animals  almost  constantly  produce  typical  tuberculosis.  In 
the  pus  of  tubercular  pyo-pneumothorax,  if  micro-organisms  are  present, 
the  bacillus  of  tuberculosis  can  be  found,  and  the  pus  shows  no  tendency 
to  undergo  putrefactive  changes,  in  contradistinction  to  empyema  occur- 
ring in  non-tuberculous  subjects,  in  whom  spontaneous  discharge  through 
the  bronchial  lUbes  takes  place.  Senator  maintains  that  putrefaction  is 
prevented  bj'  the  parenchyma  of  the  lungs  acting  as  a  filter,  preventing 
ingress  of  bacteria  with  the  inspired  air,  and  by  the  presence  of  a  large 
amount  of  carbonic-acid  gas  in  the  air  of  t'he  cavity,  as  it  is  well  known 
that  microbes  do  not  thrive  so  well  in  such  an  atmosphere  as  in  ordinary 
air.  Ehrlich  has  made  an  interesting  bacteriological  examination  of 
the  pus  in  19  cases  of  emp3-ema  ;  in  onl}^  7  of  these  could  the  bacillus 
of  tuberculosis  be  found  ;  in  the  remaining  12  this  microbe  could  not 
be  detected,  and  upon  this  negative  ground  the  existence  of  tuberculosis 
was  excluded.  Further  observation  in  these  cases  after  operation  cor- 
roborated the  diagnosis.  He  asserts,  therefore,  that,  in  the  purulent 
pleuritic  exudation  in  tubercular  patients  in  empyema  and  pyo-pneumo- 
thorax, the  presence  of  the  specific  microbic  cause  can  always  be  demon- 
strated. This  author  places  the  greatest  importance  on  a  bacteriological 
examination  of  the  pus  as  a  means  of  differential  diagnosis  between  sup- 
purative and  tubercular  empyema.  A  serous  eflusion  is  not  infrequently 
transformed  into  an  empyema  b}-  a  change  of  the  predominant  bacterio- 
logical cause.  In  a  number  of  cases  I  found  it  necessary  to  aspirate  the 
chest  for  the  removal  of  a  copious  effusion.  The  fluid  removed  at  the 
first  aspiration  was  clear  serum  ;  the  second  aspiration  removed  a  slight, 
turbid  fluid,  and  the  third  aspiration  jnelded  a  distinctly  sero-purulent 
fluid  ;  while  the  fourth  aspiration  revealed  a  well-marked  empyema.  In 
all  of  these  cases  the  subsequent  historj-  and  termination  showed  that 
tubei'culosis  was  the  primary'  cause  of  the  effusion.  Infection  of  the 
tubercular  foci  with  pus-microbes,  and  the  entrance  of  these  into  a  cavit}^ 
alread}^  changed  b}'  disease,  altered  the  type  of  the  inflammation  and  the 
character  of  the  effusion.  Putrefaction  of  the  products  of  suppurative 
pleuritis  occurs  occasionall}-  without  the  presence  of  a  direct  communi- 
cation of  the  pleural  cavity  with  the  atmospheric  air.  I  have  seen  2 
cases  of  this  kind,  and  both  recovered  after  radical  operation.     In  such 


28'2  I'KINCIPLES   OF    SURGERY. 

instances  we  must  take  it  for  granted  that  saproplntic  bacilli  find  tiieir 
wa}'  into  the  pleural  cavity  through  the  respiratory-  passages  and  the 
parenchjma  of  the  lungs,  and  select  the  products  of  coagulation  necrosis 
for  their  nutrient  medium.  The  pus  in  such  cases  is  exceedingl}^  fetid, 
thin,  and  usually  contains  large  shreds  of  fibrin.  The  ptomaines  of  the 
putrefactive  bacteria  increase  the  fever  and  other  symptoms  of  septic 
intoxication. 

Diagnosis. — The  j)resence  of  a  considerable  quantity  of  fluid  gives 
rise  to  wi'll-marked  clinical  and  physical  symptoms.  Aside  from  the 
ordinary  symptoms  Avhich  point  to  a  supi)iinitive  inflammation  in  other 
localities,  such  as  chill,  fever,  pain,  loss  of  appetite,  the  patient  complains 
of  difficulty  of  breathing,  especially  on  lying  down,  and  sometimes,  but 
not  alwa3's,  of  a  short,  hacking  cough.  On  physical  examination  it 
becomes  apparent  that  a  part  or  nearl}-  the  entire  pleural  cavity  is  occu- 
pied by  a  fluid.  Dullness  on  percussion  and  absence  of  respiratory  and 
voice  sounds  over  the  area  occupied  by  tlie  fluid,  and  displacement  of 
adjacent  organs  by  the  intra-thoracic  pressure,  are  signs  which  cannot 
be  well  simulated  by  an3^thing  else  than  accumulation  of  fluid  in  the 
pleural  cavity.  Bulging  of  intercostal  spaces,  as  a  rule,  is  more  marked 
in  empyema  than  hydro  thorax.  In  empyema  the  subcutaneous  tissues 
on  the  aflTected  side  are  often  slightly  cedematous  and  the  superficial 
veins  are  sometimes  enlarged.  In  empyema  of  the  right  pleural  cavity 
the  liver  is  pushed  in  a  downward  direction,  Avhile  the  heart  is  displaced 
toward  the  left  side.  In  empj-ema  of  the  left  side  the  apex-beat  of  the 
heart  can  quite  frequently  be  felt  on  the  right  side  of  the  sternum.  A 
temperature  of  100°  to  101°  F.  in  the  morning  and  101°  to  103°  F. 
in  the  evening,  continued  for  several  weeks,  speaks  strongly  in  favor 
of  empyema.  A  positive  diagnosis  alwaA's  rests  on  demonstrating  the 
presence  of  pus  in  the  pleural  cavity,  which  can  be  done,  without  danger 
and  without  pain  worth  mentioning,  by  an  explorator}'-  puncture  with  an 
ordinary  hypodermic  needle.  In  puncturing  the  chest  for  exploratory 
or  therapeutic  i)urposes,  it  should  be  borne  in  mind  that  the  needle 
should  be  inserted  in  a  direction  which  corresponds  to  the  centre  of  the 
intercostal  space,  consequently  in  an  oblique  direction  from  below 
upward.  If  no  contra-indications  present  themselves,  the  exploratory^ 
puncture  should  be  made  at  the  place  where,  later,  the  radical  operation 
will  1)6  performed  ;  that  is,  in  the  axillary  line,  between  the  sixth  and 
seven  til  or  seventh  and  eighth  ribs.  If  the  needle  is  perfectl}'  aseptic 
no  harm  will  result,  even  should  the  lung  or  liver  be  punctured. 

Prognosis. — Simple,  uncomplicated  suppurative  pleuritis  offers  a 
favorable  prognosis  if  subjected  to  earl}'  radical  treatment.  The  prog- 
nosis is  more  favorable  in  children  than  in  adults,  and  in  recent  than  in 


EMPYEMA.  283 

old  cases.  In  long-standing  emp3'enia  the  lung  becomes  atelectatic  from 
compression,  and  its  full  expansion  is  also  prohibited  b}'  numerous  firm 
adhesions.  In  children,  partial  expansion  of  the  lung  is  compensated 
for  by  retraction  of  the  yielding  chest-wall,  enabling  tlie  pleural  cavit}' 
to  close ;  while,  in  the  adult,  incomplete  expansion  of  the  lung  results 
in  a  physical  condition  which  renders  definitive  healing  a  difficult,  if  not 
even  an  impossible,  occurrence.  Pulmonary  tuberculosis  complicated 
by  empj-ema  constitutes  a  contra-indication  to  radical  operation,  as  the 
patient  is  already  affected  b}'  a  disease  which  almost  necessaril}-  leads 
to  a  fatal  issue,  and  a  radical  operation  would  only  hasten  this  termi- 
nation. 

A  fistulous  communication  between  a  bronchial  tube  and  the  pleural 
cavity,  resulting  from  a  rupture  of  an  empyema  in  this  direction,  in 
exceptional  cases,  leads  to  a  spontaneous  cure,  but  more  frequenth' 
becomes  a  cause  of  retardation  of  recover^'  after  an  operation. 

Treatment. — An  empjema  is  nothing  more  nor  less  than  an  abscess 
in  the  pleural  cavit}^  and  should  be  treated  as  such.  There  can  be  no 
doubt  that  in  exceptional  instances  a  cure  has  been  effected  b}'  aspira- 
tion. This  method  of  treatment  promises  more  in  children  than  in 
adults,  and  it  is  also  in  the  former  that  the  radical  operation  has  3'ielded 
the  best  results;  lience  it  is  not  advisable  to  have  recourse  to  an  uncer- 
tain procedure  if  a  radical  operation  accomplish  the  same  result  with 
greater  certainty,  more  speedil}',  and  with  no  greater  immediate  and 
remote  risks  to  life.  It  is  a  good  plan  in  every  case  to  combine  aspira- 
tion with  exploration,  for  the  purpose  of  improving  the  conditions  for  a 
radical  operation.  By  aspiration  we  demonstrate  the  presence  of  pus  in 
the  pleural  cavit}^  and,  b}^  removing  the  fluid  completel}'  or  in  part,  we 
aid  the  expansion  of  the  lung,  which,  by  the  time  the  radical  operation 
is  performed,  has  become  adherent  lower  down.  Aspiration  is  to  be 
followed,  in  the  course  of  two  or  three  days,  by  a  radical  operation.  B3' 
a  radical  operation  we  understand  incision  of  the  pleural  cavity  and 
draining  the  same.  The  operation  for  empj-ema  b}^  incision  and  drain- 
age must  alwa3-s  be  done  under  the  strictest  antiseptic  precautions,  as 
an}'  mistake  or  negligence  in  this  regard  iS  exceed ingl}'  liable  to  be 
followed  b}-  infection  with  putrefactive  bacteria, — an  occurrence  which 
would  greatly  increase  the  danger  from  sepsis.  Nothing  but  perfectly 
aseptic  material  must  be  used,  and  the  whole  chest  of  the  patient  and 
the  liands  of  the  operator  must  be  thoroughly  disinfected  by  washing 
with  hot  water  and  potash-soap,  and  disinfecting  with  a  1-to-lOOO  solu- 
tion of  sublimate,  and  finally  with  alcohol.  The  instruments  must  be 
boiled  for  at  least  ten  minutes. 

(a)    Incisions. — If  an   empyema  is  perforating   the  chest-wall  and 


28-1:  rUINCIPLES    OF    SURGEKY. 

appears  as  a  subcutaneous  abscess,  the  incision  is  made  through  the 
centre  of  the  abscess  and  parallel  to  the  ribs.  If  no  such  indication  is 
present,  the  incision  should  be  made  over  the  centre  of  the  sixth  rib  and 
parallel  to  it  on  the  right  side,  and  over  the  seventh  on  the  left,  at  a 
point  half-wa}'  between  the  nipple  and  the  axillary  line.  It  must  be 
about  4  inclies  in  length  and  extend  down  to  the  bone. 

(b)  Resection  of  Rib. — The  soft  parts,  with  the  periosteum,  are 
reflected  with  an  elevator,  which  is  then  passed  between  the  periosteum 
and  rib,  posteriorly,  from  below  upward,  and  the  periosteum  separated 
to  the  extent  of  U  inches.  If  the  elevator  is  l<ept  in  close  con- 
tact with  the  bone,  there  is  no  danger  of  injuring  the  intercostal  vessels 
or  nerves,  nor  of  opening  the  pleural  cavity  prematurel}-.  With  the 
elevator  the  rib  is  raised,  and  a  section  1^  inches  in  length  is  removed 
with  a  pair  of  heav}'  bone-forceps.  After  the  removal  of  the  bone,  all 
haemorrhage  is  carefully'  cheeked.  If  the  pleura  feel  tense  and  bulge 
into  the  wound,  there  is  no  necessity  of  making  another  exploratory 
puncture.  If  this  is  not  the  case,  as  a  matter  of  precaution,  another 
puncture  can  be  made,  at  this  stage  of  the  operation,  to  satisfy  the  sur- 
geon of  the  presence  of  pus  underneath.  The  incision  into  the  pleura 
is  then  made  with  a  bistour}-,  in  the  centre  of  the  periosteal  gutter, 
through  this  membrane  and  the  pleura,  into  the  cavity  of  the  chest.  This 
incision  must  be  large  enough  to  allow  the  insertion  of  drainage-tubes 
the  size  of  the  little  finger.  The  deep  incision  in  the  soft  parts  can  be 
readily  dilated  to  the  requisite  extent  b}^  tlie  insertion  of  a  finger, 
which  may  also  be  used  in  interrupting  tlie  flow. 

(c)  Evacuation  of  Pus  and  Removal  of  Membranes. — A  great  deal  of 
information  is  gained,  as  soon  as  the  incision  into  the  chest  has  been 
made,  in  reference  to  the  expansibility  of  the  lung.  If  this  has  not 
been  much  impaired,  the  pus  will  continue  to  escape  with  much  force, 
especially  during  inspiration.  Rapid  evacuation  is  attended  by  some 
danger,  from  overdistention  of  the  heart  and  vessels  in  the  lung,  and 
must  be  guarded  against  by  interrupting  the  flow,  from  time  to  time, 
by  inserting  the  index  finger  into  the  opening.  If  the  lung  expand 
promptly,  its  lower  margin  can  often  be  seen  through  the  opening 
toward  the  end  of  evacuation.  The  more  the  lung  expands,  the  less 
the  amount  of  air  rushing  through  the  opening  into  the  chest.  In  order 
to  prevent  syncope  u[Hm  the  sudden  diminution  of  intra-thoracic 
pressure,  during  evacuation  of  the  pus,  I  have  been  in  the  habit 
of  administering,  before  the  anaesthetic  is  given,  -^^^  grain  of 
atropia  with  |  grain  of  morphia,  h3'podermatically,  with  :in  alco- 
holic stimulant,  by  the  stomach  or  rectum.  In  cases  of  empyema 
with  a  bronchial  fistula,  and  in  cases  where   respiration  was  so  much 


EMPYEMA.  285 

embarrassed  that  I  deemed  the  administration  of  an  anaesthetic  hazard- 
ous, I  have  repeated!}'  made  the  radical  oi)eration  without  narcosis,  and 
the  remedies  which  have  just  been  mentioned  answered  an  excellent 
purpose  in  diminishing  the  pain.  If,  as  is  so  often  the  case,  the  pleura  is 
lined  with  thick,  partially-detached  membranes,  these  should  be  removed 
with  a  dull  curette,  as  they  are  invariablv  infected  with  pus-microbes, 
and  their  presence  in  the  pleural  cavity  would  prolong  the  infection  and 
retard  recovery. 

(d)  Irrigation. — Irrigation  of  the  pleural  cavity  immediately  after 
the  operation  is  positively  contra-indicated  if  a  bronchial  fistula  is  pres- 
ent, and  it  is  superfluous  if  no  putrefaction  is  present.  In  fetid  empyema 
the  cavit}'  is  washed  out  with  warm,  salicylated  w'ater  until  the  fluid 
returns  clear.  Tliis  is  followed  by  an  irrigation,  for  a  very  short  time, 
with  a  1-to-lOOO  solution  of  corrosive  sublimate.  None  of  this  solution 
should  be  nllowed  to  remain  in  the  pleural  cavit}'. 

(e)  Drainage. — Eib  resection  should  always  be  done  in  operations 
for  empyema,  as  the  si)ace  thus  created  offers  ample  room  for  the  inser- 
tion of  a  large  drain.  I  have  frequenth'  seen,  after  incision  and  drainage 
through  intercostal  space,  circumscribed  destructive  processes  of  the 
margins  of  both  ribs  from  pressure  caused  by  the  drainage-tube.  Such 
pressure  is  not  only  a  source  of  pain, but  interferes  also  with  free  drain- 
age. Resection  of  such  a  small  portion  of  a  rib  does  not  add  to  the 
gravity  of  the  operation,  and  is  of  the  greatest  utility  in  tlie  subsequent 
management  of  the  case.  The  best  drain  is  a  fenestrated  rubber  tube 
the  size  of  tlie  little  finger,  or  two  rubber  tubes,  somewhat  smaller, 
stitclied  together.  The  tube  should  be  from  4  to  6  inches  in  length, 
and  always  secured  externally  with  a  large  safety-pin,  to  prevent  its 
slipping  into  the  pleural  cavity.  Non-observance  of  this  little  precaution 
has  resulted  in  a  great  deal  of  trouble  from  drains  becoming  lost  in  ihe 
pleural  cavit}'.  The  necessity  of  making  a  counter-opening  and  of 
establishing  through  drainage  does  not  arise  often,  but,  when  such  a  pro- 
cedure becomes  necessary,  it  can  readily  be  done  with  a  large  Pean 
forceps,  which  can  be  introduced  into  the  anterior  opening,  and,  b}' 
pushing  it  through  the  intercostal  space  behind,  which  has  been  selected 
for  the  counter-opening,  an  incision  is  made  down  upon  its  point,  after 
which  the  opening  is  dilated  and  a  long  drain  drawn  through  both 
openings.  After  completion  of  the  operation  a  large  antiseptic  dressing 
is  applied. 

After-Treatment. — Daily  change  of  the  dressing  and  antiseptic  irri- 
gation will  be  necessar}'  in  fetid  empyema,  if  the  primar}'  disinfection 
has  not  proved  successful,  in  rendering  the  cavit}'  fi'ee  from  putrefactive 
bacteria  and  necrosed  material.     In  ordinary  cases  the  dressing  is  not 


'2Sfi  PRINCIPLES   OF    SURGERY. 

removed  until  it  becomes  saturated  Avitli  tlu;  discharges,  or  if  the  tem- 
perature indicate  tlie  retention  of  septic  material.  Should,  at  an}-  time, 
evidences  of  putrefaction  or  sepsis  develo]),  antiseptic  irrioations  are 
positively  indicated.  A  saturated  solution  of  acetate  of  aluminum,  an 
aqueous  solution  of  tincture  of  iodine,  a  2-per-cent.  solution  of  boraeic 
acid,  or  salicylated  water  can  be  used  for  this  purpose  ;  always  using  the 
solutions  at  blood-heat,  as  the  irrigation  of  the  pleural  cavity  with  a  cold 
or  cool  solution  has  in  a  number  of  cases  residted  in  death  from  shock. 
In  one  of  m}^  cases  the  wife  of  the  patient  irrigated  the  pleural  cavity 
with  what  she  afterward  called  a  cool  solution,  and  the  patient  died  sud- 
denl)^  with  s^^mptoms  of  collapse.  In  another  case,  a  patient  5  years 
of  age,  I  made  the  irrigation  mj^self,  using  only  water,  the  temperature, 
as  I  afterward  ascertained,  being  below  blood-heat,  when  the  patient 
suddenly  became  pulseless  and  the  respirations  ceased.  Artificial  respi- 
ration had  to  be  continued  for  a  considerable  length  of  time,  when,  to  my 
great  relief,  the  child  commenced  to  breath  spontaneousl}'^  and  the  pulse 
and  color  of  the  face  returned.  This  experience  warned  me  to  exercise 
care  in  using  solutions  of  a  proper  temperature  in  irrigations  of  the 
pleural  cavity.  The  final  expansion  of  the  lung  and  obliteration  of  the 
pleural  cavity  are  accomplished  b}^  the  granulating  process.  The  drain 
should  be  disinfected  every  time,  and  before  it  is  re-inserted  it  should  be 
dusted  with  iodoform. 

(a)  Multiple  Resection  of  Ribs. — In  cases  of  empyema  where,  after  a 
radical  oi)eration,  only  partial  expansion  of  the  lung  takes  place,  and  the 
pleural  cavit}''  cannot  close  on  account  of  the  unyielding  nature  of  the 
chest-wall,  EstUinder's  operation  of  multiple  resection  of  ribs  is  indicated. 
The  operation  consists  in  removing  sections  of  3  to  6  centimetres  in 
length  of  all  the  ribs  over  the  abscess-cavity,  for  the  purpose  of  allowing 
the  chest-wall  to  sink  in,  and  thus  remove  the  mechanical  obstacle  to 
closure  of  the  pleural  cavity.  Through  one  incision  over  an  intercostal 
space  2  adjacent  ribs  can  be  removed.  If  more  than  2  ribs  have  to 
be  resected,  I  prefer  to  make  a  single  incision  in  the  direction  of  the 
axillar}^  line,  through  which,  after  dissecting  back  the  superficial  soft 
parts  for  1  or  2  inches  on  each  side  of  the  incision,  6  or  8  ribs  can 
be  readily  resected.  Estlander's  operation  is  absolutely  valueless  in 
cases  where  the  lung  is  almost  completely  collapsed,  as  in  such  instances 
even  the  most  extensive  resection  of  ribs  would  fail  in  correcting  the 
mechanical  difficulty  in  the  way  of  a  definitive  healing  of  the  pleural 
abscess.  The  operation  is  also  contra-indicated  where  further  expansion 
of  the  lung  depends  on  incurable  lesions  of  this  organ. 

(b)  Thoracoplastic  Operation. — In  ol)stinate  cases  of  empyema, 
where  even  Estlander's  operation  fails  in  eflfecting  a  cure,  and  where  the 


LUNG-ABSCESS.  287 

difficulties  in  the  way  are  of  a  purely  mecliauifiil  nature,  Scbede  has 
recently  described  a  procedure  which,  in  reality,  is  a  plastic  operation. 
He  not  only  makes  resection  of  several  rihs,  but  resects  the  entire  tho- 
racic wall  over  the  cavity,  with  the  exclusion  of  the  skin.  He  makes  a 
skin-flap  with  its  base  directed  upward,  corresponding  in  size  to  the  cavity 
underneath,  and  then  removes  all  of  the  riljs  in  the  region  to  the  same 
extent,  and  finally  resects  the  remaining  portion  of  the  chest-wall.  This 
operation  exposes  one  side  of  the  cavity  completel}',  and  the  opposite 
wall  is  then  covered  with  the  skin-flap.  The  flap  is  not  sutured,  but  kept 
in  place  In'  a  compress  of  loose  gauze  corresponding  in  size  and  shape  to 
the  abscess-cavit}'.  This  operation  deals  more  eflrectuall3^  with  the  me- 
chanical difficulties  residting  from  imperfect  expansion  of  the  lung  than 
Estlander's  multiple  resection  of  ribs,  and  will  always  be  resorted  to  in 
proper  cases  where  less  heroic  measures  have  failed  in  accomplishing  the 
desired  result. 

LUNG-ABSCESS. 

The  successful  treatment  of  abscess  of  the  lung  by  operative  pro- 
cedure is  one  of  the  many  achievements  of  modern  surger}'.  Bull,  of 
Norway,  has  collected  26  cases  of  abscess  of  the  lung  treated  by  incision 
and  drainage,  of  which  number  4  were  cured,  6  improved,  9  relieved,  and 
7  were  not  benefited  by  the  operation.  Abscess  of  the  lung  is  the  result 
of  a  circumscribed  suppurative  inflammation  of  lung-tissue,  or  it  de- 
velops after  an  attack  of  pneumonia  or  gangrene  of  the  lung.  If  it 
follow  pneumonia,  a  part  of  the  solidified  organ  fails  to  undergo  resolu- 
tion and  becomes  the  seat  of  secondary  infection  with  pus-microbes. 
The  abscess  then  forms  by  liquefaction  of  the  inflammatory  product,  the 
same  as  in  other  tissues.  Gangrene  of  the  lung  can  only  take  place  if 
the  tissues  become  infected  with  putrefactive  bacteria  through  the 
respiratory  passages.  If  the  gangrenous  portion  is  limited  in  extent, 
and  life  is  prolonged  for  a  sufficient  length  of  time,  the  dead  tissue  be- 
comes detached,  and  is  frequently  eliminated  in  fragments  tlirough  a 
bronchi.ll  fistula  by  coughing.  The  cavity  which  is  formed  in  this  man- 
ner suppurates,  and  is  etiologically  and  clinically  an  abscess.  A  circum- 
scribed suppurative  pneumonia,  resulting  in  the  formation  of  an  abscess, 
may  occur  around  a  foreign  body  which  has  lodged  in  one  of  the  bron- 
chial tubes.  The  clinical  history  of  ever}'  abscess  of  the  lung  points  to 
an  antecedent  suppurative  pulmonary  inflammation,  with  or  without 
gangrene. 

Diagnosis. — The  surgeon  diagnosticates  the  existence  and  location 
of  an  abscess  in  the  lung  by  the  same  methods  and  means  as  when  it  is 
located  in  another  organ.  If,  from  the  clinical  history  and  physical 
examination  of  the  chest,  he  has  reason  to  suspect  that  the  cavity  is  of 


288  riviNcij'LES  OF  sukgkky. 

a  non-tuberculur  nature,  he  locates  it  as  accurately  as  he  can  by  the  physi- 
cal signs  which  ai'e  presented,  and  then  dtnnoiistrates,  ad  ociilum,  the 
existence  of  a  pus-cavity  by  exploring  the  lung  with  the  needle  of  an 
exploring-syringe.  Fenger  was  the  first  one  in  this  country  to  locate  an 
abscess  of  the  lung  by  this  means  of  examination,  and  to  adopt  treat- 
ment upon  strict  antiseptic  surgical  principles.  Microscopical  examina- 
tion of  the  sputum  is  of  great  value  in  determining  whether  an  abscess 
is  tubercular  or  the  result  of  a  suppurative  inflammation. 

Methodical  Exploration  of  Lung  for  Abscess. — If  the  physical 
symptoms  point  to  a  non-tubercular  abscess  in  the  lung,  with  or  without 
a  bronchial  fistula,  the  surgeon  will  be  able  to  determine  the  portion  of 
lung  involved  b}'  ascertaining  over  the  abscess  a  limited  area  of  dullness 
caused  b}'  condensation  of  lung-tissue  around  the  abscess,  and,  if  the 
abscess-cavity  is  filled  l)y  pus,  by  the  presence  of  this  fluid.  If  a 
bronchial  fistula  exist,  auscultation  will  reveal  the  usual  symptoms, 
caused  by  a  cavity  in  the  lung  partially  filled  with  blood.  By  means 
of  percussion  and  auscultation  it  is  ascertained  when  the  abscess  is 
nearest  the  surface,  and  at  this  point  the  lung  is  explored  with  a  hollow 
needle,  not  exceeding  in  diameter  an  ordinary  knitting-needle,  and  at  least 
4  inches  in  length,  attached  to  an  ordinaiy  hypodermatic  or  exploring 
sj^-inge.  As  a  matter  of  course,  the  needle  aud  surface  must  be  rendered 
perfectly  aseptic  before  the  puncture  is  made.  The  needle  is  pushed 
through  an  intercostal  space,  corresponding  to  the  location  of  the  disease, 
in  the  direction  of  the  centre  of  the  inflammatory  focus ;  its  entrance  into 
the  abscess-cavit}'  is  attended  by  a  sudden  loss  of  resistance.  Aspiration 
is  now  made,  and  if  pus  is  found  the  diagnosis  is  made.  If  no  pus  is 
withdrawn  the  needle  is  pushed  forward,  and  at  different  points  aspira- 
tion is  made.  If  pus  is  not  found  in  one  direction,  the  needle  is  partly 
withdrawn  and  pushed  in  another  direction,  and  this  and  additional 
tracks  are  explored  in  the  same  manner  until  the  cavity  is  located.  An 
abscess-cavity  only  partially  filled  with  pus  may  be  entered  at  several 
points  witliout  finding  pus.  If  the  surgeon  feel  sure  that  the  needle  is 
in  a  cavity,  it  might  be  well  to  make  aspiration  with  the  patient  in 
diflferent  positions,  so  as  to  bring  the  pus  in  contact  with  the  needle;  or, 
if  this  fail,  to  inject  a  mild  antiseptic  solution  through  the  needle,  which 
will  be  coughed  up  if  the  injection  reach  the  cavity.  No  operation  on 
the  lun(j  must  he  undertaken  for  abacess  nvtil  the  exact  location  of  the 
abscesH  Jias  lieen  demonstrated  by  exploratory  puncture. 

Operation. — The  first  steps  of  an  operation  for  abscess  of  the  lung 
are  the  same  as  in  radical  operations  for  empyema.  At  least  a  section 
of  one  rib  is  removed.  With  few  exceptions,  tlie  lung  will  have  become 
adherent  to  the  parietal  pleura  at  the  time  the  operation  is  undertaken, 


SUPPURATIVE   PERICARDITIS.  289 

but  if  this  is  not  the  case  it  will  become  necessar}-  to  leave  the  operation 
unfinished  rather  than  to  risk  an  onset  of  suppurative  pleuritis  after  the 
lung-abscess  has  been  opened.  In  such  a  case,  after  the  parietal  pleura 
has  been  incised,  the  wound  should  be  tamponed  with  iodoform  gauze, 
and  the  opening  of  the  abscess  postponed  until  adhesions  have  formed. 
If  adhesions  make  it  safe  to  complete  the  operation,  the  abscess  is  again 
accurately  located  b}-  exploring  with  a  needle,  and,  while  the  needle  is  in 
the  cavity,  the  lung  is  incised  with  the  knife-point  of  Paquelin's  cautery-, 
using  the  needle  for  a  guide.  By  making  the  incision  with  the  actual 
cautery  troublesome  parenchymatous  htemorrhage  is  avoided,  and  at  the 
same  time  tlie  intervening  lung-tissue  is  protected  against  infection  by  a 
tubular  eschar;  and  last,  but  not  least,  such  an  opening  is  better  adapted 
for  subsequent  free  and  ettective  drainage.  A  rubber  drain,  as  large  as 
the  track  made  by  the  cauter}-,  is  inserted  into  the  cavitj-.  If  the 
abscess  communicate  with  the  bronchial  tubes  irrigation  cannot  be 
practiced  ;  if  this  is  not  the  case  the  abscess  is  disinfected  b}-  irrigation 
with  an  antiseptic  solution.  In  either  case  iodoformization  of  the  abscess- 
cavity'  by  dusting  the  drain  with  iodoform  should  always  be  done.  If 
the  first  opening  fail  to  drain  the  abscess  satisfactoril}',  it  may  be 
necessary  to  make  a  counter-opening  at  the  most  dependent  part  of  the 
cavit3',  and  establish  another  and  more  efficient  point  for  drainage 
(Vogt-Mosler). 

The  after-treatment  in  cases  of  lung-abscess  treated  by  incision  and 
drainage  is  the  same  as  after  radical  operations  for  emp^'ema. 

SUPPURATIVE  PERICARDITIS. 
A  suppurative  inflammation  of  the  internal  surface  of  the  pericar- 
dium results  in  an  abscess  of  the  pericardium,  or  emjnjema  pericardii. 
The  disease  is  characterized  by  evidences  which  indicate  the  presence  of 
a  suppurative  inflammation  and  by  physical  signs  which  point  to  the 
presence  of  fluid  in  the  pericardial  sac.  In  some  of  the  cases  which  have 
been  reported  it  was  attended  by  little  general  disturbance,  no  chill,  and 
but  little  rise  of  temperature.  If  it  occur  as  a  complication  of  some 
other  affections,  the  symptoms  of  the  latter  often  obscure  almost  com- 
pletely those  of  the  former.  In  some  of  the  cases  the  presence  of  pus 
was  indicated  by  oedema  in  the  prfecordial  region.  If  the  quantity-  of 
pus  is  large,  the  pericardium  is  distended  and  the  intercostal  spaces  in 
front  of  the  eff'usion  are  more  prominent  than  on  the  opposite  side.  The 
area  of  dullness,  which  can  be  mapped  out  accurately  by  percussion, 
corresponds  with  the  size  of  the  expanded  pericardium.  The  impulse  of 
the  heart  is  felt  less  distinctly  and  is  more  diffuse  than  in  a  normal 
condition.    A  copious  pericardial  effusion  always  gives  rise  to  orthopnoea. 


290  PRINCIPLES   OF   SURGERY. 

Positive  proof  of  the  existence  of  a  collection  of  pus  in  the  pericardium 
can  only  be  obtained  by  an  exploratory  puncture. 

Puncture  and  Aspiration  of  Pericardium. — Puncture  and  aspiration 
of  lluid  from  the  pericardium  is  a  comparatively  harmless  procedure,  if 
it  is  practiced  with  ordinary  skill  and  care. 

West  reports  79  cases  of  paracentesis  pei'icardii.  Of  this  number 
the  operation  was  the  cause  of  death  in  1  case  only,  and  in  this  instance 
the  trocar  which  was  used  perforated  the  right  ventricle.  Six  of  the 
cases  died  during  the  lirst  twenty-four  hours,  while  in  the  remaining 
cases  the  immediate  effect  of  the  operation  was  beneficial,  and  a  nuniber 
of  cases  recovered  permanently.  In  [)uncture  of  the  pericardium  for 
diagnostic  or  therapeutic  purposes,  the  trocar  should  always  give  way  to 
a  medium-sized  needle  of  an  exploring-syringe  or  aspirator.  The  punc- 
ture is  made  under  strict  antiseptic  precautions.  The  structures  to  be 
avoided  are  the  internal  mammary-  arter3',  the  pleural  cavity,  and  the 
heart.  The  safest  place  for  puncture  is,  in  ordinary  cases,  the  fifth  left 
intercostal  space,  about  half  an  inch  or  an  inch  from  the  margin  of  the 
sternum,  through  which  the  needle  should  be  pushed  in  a  slightly  upward 
and  outward  direction,  so  as  to  avoid  wounding  the  heart.  It  has  to 
travel  1|  to  2  inches  before  it  enters  the  pericardial  cavit}-.  If  pus  is 
found  the  case  must  be  treated  by 

Incision  and  Drainage  of  the  Pericardium. — Instead  of  using  a  trocar, 
it  is  much  better  to  make  an  incision  in  the  fifth  intercostal  space,  using 
the  needle  with  which  the  exploratory  puncture  was  made  as  a  guide. 
The  same  precautions  to  prevent  syncope  as  were  recommended  in  the 
radical  opei'ation  for  empyema  should  be  resorted  to  in  these  cases, 
and  chloroform  is  preferable  to  ether  as  an  anaesthetic.  The  intercostal 
incision  need  not  exceed  an  inch  in  length,  and,  as  soon  as  the  pericardium 
has  been  opened  sufficiently  to  allow  the  escape  of  pus,  a  dressing 
forceps  may  be  inserted,  and  the  opening  enlarged  sufficiently  to  enable 
the  introduction  of  a  drainage-tube  the  size  of  an  ordinary  lead-pencil. 

Irrigation  of  the  pericardial  cavity  is  to  be  avoided  unless  suppura- 
tion is  complicated  b}-  putrefaction.  The  drainage-tube  should  not 
project  sufficiently  into  the  pericardial  sac  to  come  in  contact  with  the 
heart,  and  should  alwaj'S  be  of  soft  material,  so  as  not  to  injure  the 
heart  should  it  be  too  long.  The  antiseptic  dressing  can  be  retained 
most  effectually  w'ith  several  strips  of  rubber  adhesive  plaster,  which 
should  be  long  enough  to  encircle  the  whole  chest.  Gussenbauer,  in  a 
patient  15  vears  of  age,  suffering  from  suppurative  pericarditis  after 
osteom3-elitis,  resected  part  of  the  fifth  rib  r.otw  the  sternum  before 
incising  the  pericardium,  and  the  putient  recovered.  This  modification 
of  the  ordinary  operation  by  incision  through  the  fifth  intercostal  space 


SUPPURATIVE   PERITONITIS.  291 

will  occasionally  present  decided  advantnges  in  the  surgical  treatment  of 
pericardial  emp3'ema. 

SUPPURATm;   PERITONITIS. 

A  great  deal  of  confusion  has  recently  arisen  in  the  use  of  the  terms 
septic  and  suppurative  peritonitis.  Etiologically,  the}'  are  identical; 
clinically,  the}-  differ  in  so  far  that  septic  peritonitis  is  generall}'  diffuse, 
and  leads  to  a  rapidU'  JEjital  termination;  while  what  is  known  as  suppu- 
rative peritonitis  is  more  frequentl}"  circumscribed,  and  more  amenable 
to  surgical  treatment.  Both  forms  are  caused  bj-  infection  with  pus- 
microbes.  In  the  septic  variety'  death  results  from  sepsis  before  the 
pus-microbes  have  had  time  to  produce  their  specific  pathogenic  effect  on 
the  histological  elements  which  are  destined  to  become  converted  into 
pus-corpuscles.  In  suppurative  peritonitis  the  pus-microbes  are  either 
less  in  number  or  the}-  meet  with  conditions  less  ftivorable  to  the  pro- 
duction of  a  fatal  amount  of  ptomaines,  or,  finally,  the  peritoneum  is  in 
a  condition  which  is  unfavorable  to  the  entrance  of  pus-microbes  or  their 
ptomaines  into  the  circulation. 

Bacteriological  and  Experimental  Researches. — A  number  of  original 
investigators  have  studied  the  etiology  of  peritonitis  experimentally, 
and  their  work  has  been  of  great  practical  value  in  showing  that  sup- 
purative peritonitis  is  not  onlj'  caused  b}-  the  action  of  pus-microbes, 
but  that  it  is  equally  essential  that  certain  conditions  must  be  present 
in  the  peritoneal  cavity  Avhich  enable  the  pus-microbes  to  produce  their 
specific  pathogenic  effects.  Pawlowsky  made  ten  series  of  experiments 
on  101  animals.  The  chemical  irritants,  or  cultures,  w^ere  introduced 
into  the  peritoneal  cavit}-  through  the  canula  of  a  small  trocar  under 
strict  antiseptic  precautions,  and  the  small  wound  was  carefuU}'  sealed 
with  iodoform  collodion.  The  first  series  consisted  of  experiments 
with  croton-oil  on  3  dogs  and  9  rabbits.  The  amount  of  croton-oil 
injected  in  each  case  varied  from  6  drops  to  -^^  drop.  The  smallest 
doses  produced  no  effects.  Large  doses  produced  a  severe,  acute, 
haemorrhagic  peritonitis,  the  intensity  of  which  was  proportionate  to 
the  quantity  of  the  irritant  injected.  The  peritoneal  exudation,  under 
the  microscope,  was  seen  to  contain  red  and  white  blood-corpuscles. 
Inoculations  of  different  nutrient  media  with  the  fluid  jnelded  negative 
results.  In  the  next  series  of  experiments,  an  aqueous  solution  of  tr3'p- 
sin  and  pancreatin  was  injected  for  the  purpose  of  determining  Avhether 
the  digestive  ferments,  in  the  event  of  intestinal  perforation,  could  pro- 
duce peritonitis.  The  experiments  established  the  fact  that  trj-psin  acts 
as  a  powerful  irritant  upon  the  peritoneum.  Injection  of  ^  gramme 
of  trj'psin,  dissolved  in  distilled  water,  caused  in  rabbits  a  severe  haemor- 
rhagic  peritonitis,  with  a  copious  exudation,  and  death  in  from  four  to 


292  PRINCIPLES   OF   SURGERY. 

four  and  a  half  hours.  In  doses  of  ^  to  j'y  gramme  the  same  local  con- 
dition was  produced,  but  death  did  not  occur  until  twent}-  to  twenty- 
four  hours  after  the  injection.  One-hundredth  (.01)  of  a  gramme  pro- 
duced no  symptoms.  Nutrient  media  inoculated  with  the  products  of 
inflammation  remained  sterile.  Next,  the  peritoneal  cavity  was  infected 
with  i)late  cultures  of  dilferent  microbes  suspended  in  sterilized  water. 
The  first  experiments  were  made  with  non-pathogenic  microbes.  Four 
rabbits  and  one  dog  were  injected  with  large  quantities  of  a  micrococcus, 
which  was  obtained  from  a  plate  culture  inoculated  with  pus;  the  micro- 
coccus was  exactly  similar  to  the  staphylococcus  p3'ogenes  albus,  for 
which  it  was  first  mistaken.  Later,  it  was  shown  that  it  was  not  a  pus- 
microbe,  as  it  did  not  liquefy  gelatin.  All  of  the  animals  recovered. 
Two  rabbits  inoculated  with  an  entire  culture  of  yellow  sarcinae  upon 
agar-agar,  mixed  with  j^(j  drop  of  croton-oil,  also  recovered.  The 
experiments  with  pathogenic  microbes  always  produced  positive  results. 
Three  series,  with  three  separate  micro-organisms,  were  made  next. 
The  staphylococcus  pyogenes  aureus,  grown  from  osteom3'elitic  pus, 
was  first  used.  In  11  out  of  41  experiments  this  microbe  alone  was 
used  ;  in  11  it  was  mixed  with  croton-oil,  in  6  with  trypsin,  and  in  7  with 
agar-agar.  In  all  cases  where  pure  cultures  were  used  peritonitis  was 
produced,  the  type  varying  according  to  the  number  of  microbes  used. 
The  same  microbes  could  be  cultivated  upon  proper  nutrient  media  from 
the  difl'erent  inflammatory  products.  In  hardened  specimens  of  the 
inflamed  peritoneum,  stained  with  different  coloring  agents,  the  micro- 
organisms could  be  seen  in  the  Ij^mph-spaces.  The  suppurative  tj'pe  of 
peritonitis  thus  artificially  produced  became  more  apparent  the  longer 
life  was  prolonged.  An  entire  agar-agar  culture  of  the  bacillus  pj^o- 
cyaneus  caused  death  from  septic  peritonitis  in  from  twenty-four  to  forty- 
eight  hours.  One-fifth  of  this  quantity  proved  harmless.  The  next 
series  of  experiments  was  made  to  ascertain  the  cause  of  peritonitis 
after  intestinal  perforation.  The  fresh  intestinal  contents  of  a  healthy 
animal,  just  killed,  were  divided  into  three  parts,  one  of  which  was  at 
once  injected  into  several  rabbits,  without  filtration,  in  doses  of  1 
syringe ful.  The  second  portion  was  filtered,  and  of  the  filtrate  from  2 
to  3  syringefuls  were  injected  into  each  rabbit.  The  third  portion  was 
sterilized,  according  to  TyndnU's  directions,  for  eight  days,  and  then  1 
syringeful  was  injected  into  the  abdominal  cavity  of  each  animal.  The 
results  were  as  follow :  Four  rabbits  died  of  fibrinous,  suppurative 
peritonitis  from  the  injections  with  the  first  portion.  Four  rabbits 
injected  with  the  filtered  fteces  recovered,  as  did  one  animal  inoculated 
with  the  sterilized  portion. 

At  the  necropsy  particles  of  the  faeces  were  found  in  the  peritoneal 


SUPPURATIVE    PERITONITIS.  293 

cavit}'  covered  with  fibrin,  and  a  peculiar,  short  bacilhis  was  found  in 
the  inflammatory  exudate.  This  bacillus  he  believed  to  be  the  cause  of 
peritonitis, and  consequently  termed  it  hacillus  peritonitidus  ex-intestiualis 
cuniculi.  The  cultures  of  this  bacillus  upon  agar-agar  he  describes  as 
shining,  gra3'ish-white,  oil-paint-like  colonies.  With  cultures  of  this 
bacillus  he  made  9  experiments  on  rabbits  and  2  on  dogs.  Everj^ 
animal  which  received  an  entire  agar-agar  culture  died  of  haemorrhagic 
peritonitis  in  from  twenty  to  twentj^-four  hours.  In  smaller  quantities, 
death  from  the  same  cause  sometimes  did  not  occur  until  at  the  end  of 
the  third  da}'.  Still  smaller  doses  produced  a  suppurative  peritonitis 
and  death  after  a  number  of  da^^s.  Of  the  2  dogs,  each  injected  with  an 
agar-agar  culture,  1  died  after  twent3'-four  hours  of  septic  peritonitis, 
the  other  recovered  after  an  illness  of  several  days'  duration.  In  the 
fatal  cases  the  bacillus  was  found  in  different  organs,  and  could  again 
be  reproduced  by  inoculations  with  infected  tissues  upon  nutrient  media. 
This  author  maintains  that  the  fibrinoids  form  of  peritonitis  is  the  least 
dangerous,  as  the  layers  of  fibrin  tend  to  limit  the  entrance  of  microbes 
into  the  circulation,  while  the}'  also  retard  the  local  diff"usion  of  the  in- 
jection. The  fibrino-suppurative  A'ariety  is  the  next  least  dangerous 
form,  while  in  the  most  rapidly  fatnl  cases  of  septic  peritonitis  the  local 
lesion  is  not  characterized  b}'  any  macroscopical  tissue  changes.  Wegner 
has  shown  by  his  experiments  that  a  great  variety  of  fluids  from  septic 
microbes,  such  as  water,  bile,  urine,  blood,  etc.,  can  be  injected  into  the 
peritoneal  cavity  of  rabbits  without  any  serious  results  following ;  even 
large  quantities  of  unfiltered  air,  when  introduced  in  the  same  manner, 
proved  inuocuous.  Putrescible  substances,  when  injected  in  small  quan- 
tities, were  rapidly  absorbed  without  producing  peritonitis ;  but  when 
the  quantity  injected  was  large,  and  insufllation  of  unfiltered  air  was 
practiced  at  the  same  time,  peritonitis,  with  putrefaction  and  death  from 
septic  intoxication,  occurred.  Grawitz  proved  that  saprophytic  bacteria, 
when  injected  into  a  normal  peritoneal  cavity,  were  promptly  destroyed 
and  absorbed.  In  cases  in  which  the  injection  was  made  into  a  perito- 
neal cavity  which  had  previousl}'  undergone  alterations  b}'  injur}'  or  dis- 
ease, or  in  which  the  quantity  of  fluid  was  too  great  for  speedy  absorp- 
tion, symptoms  of  intoxication,  as  described  by  Weber,  resulted,  but 
these  syn)ptonis  were  unaccompanied  by  suppurative  peritonitis.  A 
healthy  peritoneal  cavity  has  also  been  found  capable  of  disposing  of  a 
limited  quantity  of  pure  cultivations  of  pus-microbes,  the  microbes 
being  removed  by  absorption  and  destroyed  in  the  circulation,  or  elimi- 
nated through  the  excretory  organs.  But  when  pyogenic  organisms  are 
introduced  into  an  abdominal  cavity,  in  which  the  absorptive  capacity 
of   the   peritoneum  has  been   diminished  or   suspended  by  antecedent 


294  PRINCIPLES   OF    SURGERY. 

pathological  conditions,  suppurative  peritonitis  is  the  usual  result. 
When  pus-microbes  are  introduced  in  large  quantities,  even  into  a 
healthy  peritoneal  cavity,  the  preformed  ptomaines,  by  their  chemical 
action,  so  alter  the  tissues  that  tlie  process  of  absorption  is  impaired, 
and  suppurative  peritonitis  again  results  in  consequence  of  the  retention 
of  pus-microbes  in  tissues  prepared  for  their  pathogenic  action. 

Orth  agrees  with  Grawitz,  that  when  a  pure  culture  is  injected  into 
a  healthy  peritoneal  cavity  suppuration  does  not  necessarily  take  place. 
But  his  experiments  prove,  what  is  of  the  greatest  practical  interest,  that, 
if  the  peritoneum  is  wounded  under  antiseptic  precautions,  peritonitis 
invariabl}^  follows,  if  suppuration  exist  elsewhere  in  the  body  at  the 
same  time.  If,  for  instance,  an  abscess  in  the  subcutaneous  tissue  was 
artificially  produced  in  animals,  and  then  the  intestine  was  rendered  tem- 
porarily impermeable,  death  from  suppurative  peritonitis  was  the  rule. 
The  same  result  followed  if  the  pus-microbes  were  injected  directly  into 
the  circulation,  but  not  if  the}'  were  introduced  through  the  alimentary 
canal.  Rinne  is  of  the  opinion  that,  on  account  of  the  rapidity  witli 
which  absorption  takes  place  in  the  peritoneal  cavit}',  the  peritoneum, 
when  in  a  normal  condition,  is  almost  immune  to  infection  with  pus-mi- 
crobes. He  injected  from  30  to  35  cubic  centimetres  of  a  pure  culture  of 
pus-microbes,  suspended  in  sterilized  water,  into  the  peritoneal  cavity  of 
healthy  animals,  and  never  succeeded  in  this  manner  in  producing  perito- 
nitis. He  had  no  better  success  with  injections  of  a  mixture  of  a  gelatin 
culture  of  staphylococcus  pyogenes  aureus  and  a  turbid  bouillon  culture 
of  the  same  coccus.  He  also  made  daily  injections  with  a  putrid  fluid, 
to  which  was  added  a  culture  of  the  staphylococcus  pyogenes  aureus, 
without  producing  peritonitis.  The  experiments,  as  a  rule,  were  made 
on  dogs,  although,  in  several  instances,  rabbits,  guinea-pigs,  and  white 
rats  were  used.  He  believes  tliat  the  difference  in  the  results  obtained 
by  him  and  Grawitz,  as  compared  with  Pawlowsky,  consists  in  the  nature 
of  the  abdominal  wound.  Pawlowsk}'  made  an  incision  down  to  the 
muscles  and  then  perforated  the  abdominal  wall  with  a  blunt  trocar  ;  while 
he  and  Grawitz  used  a  sharp,  hollow  needle  for  making  the  intra-perito- 
neal  injection.  To  prove  that  his  injections  reached  the  peritoneal  cavit}', 
he  added  coal-dust  to  the  fluid,  which  he  found  at  the  post-mortems  as 
fine  particles  clinging  to  the  peritoneal  surface. 

Clinical  and  Bacteriological  Studies. — Frankel  found  the  strepto- 
coccus p3'ogenes  in  a  great  variety  of  puerperal  diseases,  especially  in 
cases  in  which  the  local  afl'ection  implicated  tlie  lymphatic  vessels.  In 
such  cases  the  microl)es  found  entrance  into  tlie  pelvic  tissues  from  abra- 
sions or  ulcers  in  the  vagina,  and  by  extension  of  the  inflammatory 
process  the  broad  ligaments  and  the  peritoneum  are  successively  reached  ; 


SUPPURATIVE   PERITONITIS.  295 

after  the  peritoneum  has  once  been  reached  rapid  diffusion  takes  place, 
and,  finallj^  the  diaphragm  and  pleura  are  implicated  in  the  same  process, 
and  the  microbes  reach  the  blood  and  cause  sepsis  and  pyaemia. 

Weichselbaum  has  shown  that  peritonitis  is  not  always  caused  by 
pus-microbes,  as  lias  been  heretofore  believed,  as  he  found  the  diplo- 
coccus  of  pneumonia  unaccompanied  by  any  other  micro-organism  in 
3  cases  of  peritonitis.  In  1  case  peritonitis  and  pneumonia  existed 
at  the  same  time;  in  the  other  double  pleuritis  followed  the  peri- 
tonitis; but  in  the  last  case  peritonitis  was  undoubtedly  primar}-,  and, 
in  the  absence  of  any  other  microbes  in  the  products  of  the  inflamma- 
tion, must  have  been  caused  by  the  diplococciis  of  Friedlander.  There 
can  be  no  doubt  that  septic  peritonitis  may  be  caused  by  pathogenic 
microbes  which,  at  present  at  least,  are  not  classified  with  the  pus- 
microbes ;  but  suppurative  peritonitis  can  have  no  other  bacteriological 
cause,  and  in  most  cases  of  septic  peritonitis  infection  with  pus- 
microbes  can  be  demonstrated  by  clinical  evidences  as  well  as  bacterio- 
logical and  experimental  demonstration. 

Difference  between  Plastic  and  Suppurative  Peritonitis. — The  great- 
est clinical  difference  between  simple  or  plastic  peritonitis  produced  by 
trauma  or  chemical  irritants  and  septic  or  suppurative  peritonitis  con- 
sists in  the  cause  and  extent  of  the  inflammation.  Plastic  inflammation 
produced  b}'  aseptic  causes  remains  limited  to  the  seat  of  trauma  or 
chemical  irritation,  and  does  not  extend  much  bej'ond  the  surface-area 
to  which  the  stimulus  is  applied  ;  while  septic  peritonitis  is  alwa3's  char- 
acterized b}'  its  progressive  character,  as  the  cause  upon  which  it  de- 
pends is  reproduced  within  the  peritoneal  cavit}'.  A  plastic  peritonitis 
is  attended  by  febrile  disturbances,  caused  b}'  the  introduction  into  the 
circulation  of  the  products  of  coagulation  necrosis  or  metabolic  tissue 
changes;  in  septic  peritonitis  the  general  symptoms  are  produced  by 
the  entrance  of  pus-microbes  into  the  general  circulation  and  their 
ptomaines,  both  of  which  are  also  reproduced  in  tiie  blood  and  other 
organs  of  the  body  in  which  secondary  localization  ma}-  take  place. 

The  Causes  of  Suppurative  Peritonitis. — Experimental  research  has 
demonstrated  that  in  the  causation  of  suppurative  peritonitis  two  con- 
ditions must  be  present  at  the  same  time  :  1.  Pyogenic  bacteria.  2.  A 
wound  of  the  peritoneal  surface,  or  antecedent  pathological  conditions 
which  diminish  the  absorptive  capacity  of  the  peritoneum.  The  microbic 
cause  is  the  essential  etiological  factor,  as  without  it  the  other  conditions 
would  not  result  in  this  form  of  peritonitis.  If  pus-microbes  are  intro- 
duced into  the  peritoneal  cavity  in  sufficient  quantitj',  suppurative  peri- 
tonitis is  produced,  as  the  preformed  ptomaines  create  the  indirect 
etiological  conditions.     A  number  of  bacteria  which  at  present  are  not 


296  PRINCIPLES   OF   SURGERY. 

classified  with  the  pus-microbes  may,  iiiuler  certain  favorable  conditions, 
manifest  pyogenic  properties  ;  and  thus,  when  introduced  into  a  peritoneal 
cavity  predisposed  to  suppuration,  cause  an  attaclv  of  supi)urative  peri- 
tonitis. Thus  we  have  seen  that  AVeiehselbauni  luis  found  the  diplo- 
coccus  of  pneumonia  in  the  intlannnator}'  product  of  3  cases  of 
peritonitis,  and  as  no  other  microbes  were  present  it  is  reasonable  to 
assume  that  suppuration  was  caused  by  this  mici'obe.  In  serous  cavities 
gonorrhoeal  pus  produces,  as  a  rule,  a  circumscribed  abscess.  Sinclair, 
in  his  excellent  monograph  on  "  Gonorrhoeal  Infection  in  Women,"  after 
describing  the  gonorrhoeal  infection  from  the  vagina,  says:  "The  proper 
character  and  the  results  of  the  pathogenous  activity  of  the  gonorrhoiic 
microbes  are  therefore  seen — pure  and  unadulterated  in  the  tube.  They 
cause  purulent  inflammation  of  the  mucous  membrane,  but  the  surround- 
ing connective  tissue  remains  free  from  them.  The  gonorrhoeic  tubal 
pus  is  evacuated  into  the  peritoneum,  and,  whereas  in  other  conditions 
the  bursting  of  an  abscess  into  the  abdominal  cavity  is  followed  by  the 
gravest  consequences,  in  this  case  the  whole  process  terminates  with  a 
circumscribed  inflammation,  encapsuling  the  exuded  pus.  The  cause  of 
this  difference  is  the  varying  pathogenic  value  of  the  organisms  which 
are  contained  in  the  pus.  A  puerperal  pelvic  cellulitic  abscess,  bursting 
into  the  peritoneum,  causes  general  peritonitis,  because  it  contains 
pyogenous  streptococci,  which  rapidly  multiply  in  serous  cavities,  and 
are  capable  of  exerting  the  most  deleterious  effects.  Gonorrhoeal  tubal 
pus  cannot  do  this  ;  its  microbes  do  not  find  in  the  peritoneum  con- 
ditions for  their  increase  ;  the  pus,  therefore,  acts  as  an  aseptic  foreign 
bod}',  becomes  encapsuled,  and  is  finall}'  absorbed.  Practically,  it  is  well 
known  that  when  gonorrhoeal  infection  extends  from  the  Fallopian  tubes 
to  the  peritoneum  by  leakage  of  pus  into  the  peritoneal  cavity  from 
the  peritoneal  extremity  of  the  tube,  or  rupture  of  a  pus-tube,  the 
result  is  a  circumscribed  suppurative  peritonitis,  with  the  formation  of 
a  circumscribed  abscess." 

That  this  favorable  termination  does  not  invariabl}^  follow  gonor- 
rhoeal infection  of  the  peritoneal  cavity  is  well  shown  by  a  case  reported 
by  Loven,  which  is  by  no  means  an  isolated  one.  The  source  of  infec- 
tion could  not  be  learned  in  this  case,  but  the  diagnosis  of  gonorrhoeic 
ascending  infection  was  positive.  The  disease  commenced  as  an  ordinary 
vnlvo-vaginal  blennorrhoea,  which  consecutively  extended  to  the  uterus. 
Fallopian  tubes,  and  terminated  in  })elvic  and  diffuse  peritonitis.  It  is 
possible  that  in  this  particular  case  a  secondary  infection  Avith  [)us- 
niicrobes  had  taken  place,  as,  at  the  necropsy,  chain  cocci  were  found  in 
the  peritoneal  cavit3\  The  relation  of  the  streptococcus  of  er^'sipelas  to 
peritonitis  will  be  considered  in  the  chapter  on  Er3'Sipelas.     Abdominal 


SUPPURATIVE    PERITONITIS.  297 

surgeons  are  very  well  aware  of  the  clinical  fact  that  septic  or  sup- 
purative peritonitis,  after  laparotoni}^  is  more  prone  to  develop  if  fluids, 
and  especially  blood,  are  allowed  to  remain  in  the  abdominal  cavit}- ;  and 
consequently  resort  to  a  careful  toilet  of  the  cavit}',  and,  if  there  is  auj' 
reason  to  expect  a  re-accumulation,  to  drainage.  Fluid  in  the  peritoneal 
cavity  prevents  the  removal  of  the  pus-microbes  b}'  absorption,  and  if 
they  remain  the}'^  multiply  and  cause  peritonitis.  For  years  it  has  been 
customary  to  resort  to  the  use  of  opium  in  the  prevention  and  treatment 
of  peritonitis,  until  Tait  showed  the  lallacy  of  such  treatment  and  recom- 
mended cathartics  in  threatened  cases  of' peritonitis.  The  treatment 
of  incipient  peritonitis  bj'  a  brisk  saline  cathartic  is  now  generalh' 
practiced,  and  the  results  have  been  exceedingl}-  satisfactor}'.  AVhat  is 
the  modus  operandi  of  saline  cathartics  in  the  prevention  of  diftuse 
septic  peritonitis  ?  The  most  rational  answer  to  this  question  is  that  a 
brisk  saline  cathartic  promotes  absorption  of  fluids  from  the  peritoneal 
cavity,  and  by  so  doing  removes  the  indirect  causes  of  peritonitis,  and, 
at  the  same  time,  favors  the  elimination  of  pyogenic  microbes.  Intra- 
abdominal wounds  not  covered  with  peritoneum  are  potent  factors  in  the 
development  of  peritonitis  in  an  abdominal  cavitj'^  which  is  not  abso- 
luteh"  aseptic,  as  the  raw  surfaces  furnish  a  considerable  quantity  of 
wound-secretion,  on  the  one  hand,  and,  on  the  other,  diminish  the  ab- 
sorptive capacit}"  of  the  peritoneum.  This  cause  of  peritonitis  sliould 
be  avoided  as  far  as  possible,  in  all  intra-abdominal  operations,  b}-  avoid- 
ing unnecessarj'  injury  to  the  peritoneum,  and  hy  covering  denuded  sur- 
faces with  this  membrane  wherever  it  can  be  done.  Another  indirect 
cause  of  peritonitis  is  intestinal  obstruction.  The  intestine  above  the 
seat  of  obstruction  becomes  dilated,  congested,  softened,  and,  in  con- 
sequence of  these  changes,  permeable  to  pathogenic  microbes,  which  are 
always  present  in  the  intestinal  canal  under  these  circumstances. 

Alapy  has  made  a  series  of  experiments  in  Weichselbaum's  labora- 
torj'  to  ascertain  if  pathogenic  microbes  could  pass  through  the  healthy 
stomach  into  the  intestines.  He  experimented  with  pus-microbes  and 
the  streptococcus  of  erysipelas.  From  these  experiments  he  came  to  the 
conclusion  that  the  virulence  of  these  microbes  is  destroyed  in  a  healtliy 
stomach,  but  wlien  the  gastric  secretion  has  suffered  diminution  of 
aciditj',  or  has  become  alkaline,  the  microbes  do  not  lose  their  patho- 
genic properties,  and  pass  into  the  intestines  in  an  active  condition.  In 
cases  of  intestinal  obstruction  the  physiological  functions  of  the  stomach 
are  disturbed,  and  conditions  are  created  which  preserve  the  viruUMicc 
of  pathogenic  micro-organisms  on  their  way  into  the  intestinal  caniii. 
The  immediate  cause  of  death  in  manj^  cases  of  intestinal  obstruction  is 
diflfuse  septic  peritonitis.     In  the  different  forms  of  perforative  perito- 


298  PRINCIPLES   OF   SURGERY. 

nitis  the  disease  is  caused  by  the  escape  of  fluids  containing  pyogenic 
bacteria,  and  the  type  and  gravity  of  the  disease  is  greatly  modified  by 
the  amount  of  fluid  which  enters  tlie  peritoneal  cavity  and  the  number 
of  microbes  which  it  contains.  Perforation  of  a  typhoid  or  tubercular 
ulcer  is  always  a  grave  occurrence,  as  the  fluid  whicb  escapes  is  usually 
considerable  in  quantity  and  contains  numerous  pathogenic  microbes, 
rerforating  ulcer  of  the  stomach  is  more  frequentl^^  followed  by  circum- 
scribed [)lastic  peritonitis,  which  shuts  out  the  general  peritoneal  cavity. 
Perforation  of  the  appendix  vermiformis  is  followed  as  often  by  circum- 
scribed suppurative  peritonitis  as  !)>'  diffuse  septic  peritonitis.  The  same 
can  be  said  of  i)erf()r;ition  of  the  gall-bladder. 

Symptoms  and  Diagnosis. — DiHuse  septic  peritonitis  spreads  over 
the  entire  peritoneal  cavit}-  almost  with  lightning  si^eed.  The  first 
symptoms  are  those  of  shock.  If  the  disease  follow  an  abdominal 
section,  it  is  often  difficult  to  determine  whether  the  conditions  presented 
are  due  to  shock  or  diffuse  peritonitis,  as  the  latter  may  set  in  in  a  few 
hours  after  the  operation  and  prove  fatal  within  twenty-four  hours. 
The  temperature  is  variable.  It  may  remain  normal  or  become  even. 
subnormal,  or  it  may  at  first  be  onl}'  slightl}^  increased  and  graduall}' 
reach  102°  to  104°  F.  Vomiting  and  diarrhoea  are  frequently  conspicuous 
symptoms.  In  other  cases  the  symptoms  point  to  intestinal  obstruction. 
In  extensive  plastic  peritonitis  the  immobilization  of  a  considerable 
portion  of  the  small  intestine  may  give  rise  to  persistent  vomiting  and 
absolute  constipation.  Again,  arrest  of  the  ftecal  circulation  may  be 
caused  b}'  the  tympanites  alone,  while  perforative  peritonitis  is  attended 
by  a  local  and  general  shock,  which  causes  intestinal  paresis  through  the 
sympathetic  nerves.  Heusner  has  observed  that  perforative  peritonitis 
gives  rise  to  disturbances  simulating  intestinal  obstruction  ))y  arresting 
intestinal  movements.  He  narrates  the  histories  of  2  cases  of  this 
kind  in  which  the  symptoms  of  intestinal  obstruction  w^ere  so  prominent 
that  laparotomy  was  performed.  In  both  cases  perforative  peritonitis, 
but  not  occlusion,  wms  found.  Henrot,  in  his  classical  monograph  on 
"  Pseudo-Strangulation,"  describes  a  number  of  cases  of  perforation  of 
the  gall-bladder  and  the  processus  vermiformis,  where  the  symptoms 
during  life  had  pointed  so  strongly  to  the  existence  of  intestinal  obstruc- 
tion that  a  wrong  diagnosis  was  made  b}-  able  clinicians.  He  also  calls 
attention  to  those  cases  of  paralytic  obstruction  which  are  often  observed 
after  herniotom}',  and  in  cases  of  strangulation  of  the  appendix  vermi- 
formis and  testicle.  The  intestinal  paresis,  where  it  is  not  the  result  of 
inflammation,  must  be  looked  upon  as  a  reflex  symptom. 

Physical  signs  and  sj'mptoms  are  sometimes  utterly  inadecjunte  to 
distinguish  between  acute  intestinal  obstruction  and  diffuse  peritonitis. 


SUPPURATIVE   PERITONITIS.  299 

In  differentiating  between  these  two  conditions,  it  must  be  remembered 
that,  in  the  absence  of  a  tumor,  absolute  constipation  and  faecal  vomiting 
are  the  most  characteristic  S3'mptoms  of  obstruction,  and  that  in  peri- 
tonitis the  pain  is  severe  and  continuous,  with  diffuse  tenderness, 
tympanites,  and  absence  of  visible  intestinal  coils.  In  mechanical 
obstruction  of  the  bowels  the  temperature  is,  as  a  rule,  not  above  normal 
unless  complications  have  set  in  ;  while  in  peritonitis  a  rise  in  tempera- 
ture is  the  rule,  although  in  some  of  the  gravest  cases  it  is  subnormal. 
Many  cases  of  supposed  recover^'  from  intestinal  obstruction  without 
operation  undoubtedly  were  cases  of  dynamic  obstruction,  and  the 
recovery  was  either  entirelj^  spontaneous  or  facilitated  by  means  which 
assisted  in  the  restoration  of  peristaltic  action.  In  1851  a  patient  was 
admitted  into  Dupuytren's  ward  with  well-marked  s^nnptoms  of  acute 
intestinal  obstruction.  This  eminent  surgeon  gave  it  as  his  opinion  that 
without  an  operation  a  fatal  termination  was  inevitable,  but  the  patient 
objected  to  the  operation  and  was  transferred  to  another  ward,  where  he 
recovered  in  three  da}^  under  the  use  of  simple  cathartics. 

Numerous  similar  cases  could  be  cited  in  illustration  of  the  difficulty 
of  differentiating  in  all  cases  between  mechanical  occlusion  and  dynamic 
obstruction.  In  cases  of  perforative  peritonitis  and  peritonitis  with 
putrefaction  the  presence  of  gas  in  the  free  peritoneal  cavitj'  gives  rise 
to  an  important  physical  sign.  In  tympanites  from  peritonitis  and  intes- 
tinal obstruction,  the  distended  intestines  push  the  liver  in  an  upward 
direction  ;  hence,  on  percussion,  the  liver  dullness  is  transferred  higher 
up.  But,  under  the  circumstances  mentioned  above,  the  gas  in  the  free 
abdominal  cavity  occupies  the  space  between  the  liver  and  the  chest- 
wall ;  consequently",  the  liver  dullness  has  disappeared,  and  the  space 
over  the  organ  is  tympanitic  on  percussion.  One  of  the  most  constant 
signs  in  peritonitis  is  the  small,  rapid,  compressible  pulse.  In  diffuse 
peritonitis  it  usually  ranges  between  120  and  140.  In  rapidly  fatal 
diffuse  septic  peritonitis  pain  is  often  wanting.  In  circumscribed  peri- 
tonitis pain  and  tenderness  are  limited  to  the  affected  region.  T3-m- 
panites  is  often  a  most  distressing  sj-mptom  in  circumscribed  peritonitis, 
and  may  be  entirely  absent  in  the  most  fatal  form  of  septic  peritonitis. 
Rigidity  of  the  abdominal  muscles  is  an  indication  of  peritonitis,  while 
it  is  absent  in  uncomplicated  intestinal  obstruction.  In  suppurative 
peritonitis  the  i)resence  of  pus  is  indicated  b}'  the  physical  S3mptoms 
arising  from  the  accumulation  of  fluid,  either  in  the  free  peritoneal 
cavit}-  or  in  a  circumscribed  space  of  it.  If  the  pus  is  not  confined  b}^ 
adherent  intestines  and  plastic  exudation,  it  will  gi'aA'itate  toward  the 
most  dependent  portion  of  the  peritoneal  cavit3',and  on  this  account  the 
area  of  dullness  will  var3-  according  to  the  position  of  the  patient.     In 


300  rRINCIPLES   OF   SURGERY. 

circumscribed  suppurative  peritonitis  the  pus  is  confined  in  <a  limited 
space  b}'  adherent  abdominal  organs  and  fibrinous  exudation,  and  will 
then  present  all  the  signs  and  sj-mptonis  of  a  deep-seated  abscess.  To 
determine  tlie  character  of  peritoneal  effusion,  or  of  the  contents  of  a 
circumscribed  intra-peritoneal  inflammatorj'  swelling,  it  is  necessary  to 
resort  to  an  explorator}^  puncture.  The  needle  is  inserted  at  a  point 
where  the  fluid  is  in  contact  with  the  abdominal  wall,  and,  in  the  circum- 
scribed form  of  peritonitis,  in  a  place  where  the  puncture  can  be  made 
without  traversing  the  free  peritoneal  cavity. 

Treatment. — In  perforative  peritonitis  cathartics  are  absolutely  con- 
tra-indicated, as  increased  peristalsis  would  aggravate  the  existing  con- 
ditions by  increasing  the  extravasation  and  by  preventing  limitation  of 
the  infection.  In  such  cases  opium  should  l)e  administered  to  diminish 
the  peristalsis,  to  relieve  pain,  and  to  diminish  shock.  The  subsequent 
safety  of  the  patient  will  rest  on  an  early  radical  treatment  by  laparot- 
omy. Unless  the  location  of  the  perforation  can  be  ascertained  before- 
hand, the  incision  should  be  made  in  the  median  line.  In  cases  of 
perforation  of  the  appendix  vermiformis,  an  incision  extending  from  the 
middle  of  Poupart's  ligament  to  a  point  half-wa}^  between  the  anterior- 
superior  spinous  process  of  the  ilium  and  umbilicus  will  secure  most 
direct  access  to  the  seat  of  perforation.  Perforating  tubercular  and 
typhoid  ulcers  ai-e  found  most  frequentl}' in  the  ileo-csecal  region.  If,  on 
opening  the  abdominal  cavit}^,  the  perforation  cannot  be  readil3'  found,  it 
is  better  to  resort  to  rectal  insufflation  of  hydrogen-gas  at  once,  which 
will  show  with  unfailing  certainty  not  only  that  a  perforation  exists, but 
also  its  exact  location.  In  multiple  perforations  the  same  diagnostic 
test  is  almost  indispensable,  as  it  will  avoid  the  great  mistake  of  leaving 
a  perforation  unsutured.  The  perforations  are  treated  in  the  same  man- 
ner as  an  incised  wound.  Care  must  be  taken  to  suture  the  opening  in 
a  direction  that  will  interfere  the  least  with  the  lumen  of  the  intestine. 
Fine  aseptic  silk  should  always  be  used  in  preference  to  catgut ;  at  least 
two  rows  of  sutures  must  be  ai^plied. 

After  suturing  the  perforation  the  abdominal  cavity  is  washed  out 
freely  with  sterilized  water.  Drainage  in  these  cases  must  never  be 
omitted,  as  the  operator  has  no  assurance  that  the  peritoneal  cavity  has 
been  rendered  perfectly  aseptic.  A  threatened  septic  peritonitis  after 
laparotomy  can  often  be  aborted  by  giving  half  an  ounce  of  sulphate  of 
magnesia,  dissolved  in  a  glassful  of  water,  upon  the  appearance  of  the 
first  sj'mptoms.  The  action  of  the  saline  cathartic  can  be  hastened  and 
its  beneficial  efiects  increased  by  the  administration  of  a  turpentine 
enema.  After  the  bowels  have  been  moved  thoroughl}'  opium  can  be 
given  in  sufficient  doses  to  relieve  pain.     If  the  symptoms  do  not  sub- 


SUPPURATIVE    PEKITONITIS.  301 

side  under  this  treatment,  the  abdominal  "vvound  is  opened  sufficiently 
to  permit  free  irrigation  with  salicylated  water,  and  a  Keith  drain  is 
inserted.  The  free  end  of  the  drainage-tube  is  kept  plugged  with  aseptic 
cotton.  The  fluid  in  the  tube  is  removed  everj'  two  or  tiiree  hours  by  as- 
piration. Many  surgeons  of  the  present  time  doubt  the  occurrence  of  peri- 
tonitis without  a  local  source  of  infection,  and  there  can  be  no  doubt 
that  so-called  spontaneous  peritonitis  without  such  a  local  focus  is  ex- 
ceedingly rare,  but  its  existence  cannot  be  denied.  If  suppuration  in  a 
joint  in  the  pleural  cavit}'  in  the  pericardium  can  occur  without  such  a 
direct  local  cause,  there  is  no  reason  why  suppurative  peritonitis  should 
not,  at  least  in  exceptional  cases,  have  a  similar  origin.  A  locus  minoris 
resistentise  of  a  non-suppurative  type  in  an 3^  part  of  the  peritoneal  cavit}'" 
can  determine  localization  of  pus-microbes  here  as  well  as  in  an}-  other 
part  of  the  bod^'.  In  opening  the  abdomen  for  the  evacuation  of  pus, 
the  surgeon  must  look  for  a  primar}-  lesion,  but  he  will  not  always  find 
it,  as  it  is  not  invariably  present.  Difi'use  septic  and  suppurative  peri- 
tonitis are  seldom,  if  ever,  cured  b}'  laparotomj-.  Localized  suppurative 
peritonitis  brought  about  by  curable  causes  is  amenable  to  successful 
surgical  treatment.  An  operation  is  indicated  as  soon  as  the  presence  of 
pus  is  ascertained.  Dehiy  is  dangerous  in  these  cases,  as  the  delicate 
walls,  composed  of  plastic  exudation,  may  3'ield  to  the  pressure  and  ex- 
travasation of  pus,  infect  a  new  portion  of  the  peritoneal  cavity,  or  per- 
haps its  entire  extent.  In  circumscribed  suppurative  peritonitis  the 
incision  is  to  be  made  at  a  point  where  the  pus  is  in  contact  with  the 
abdominal  wall.  The  abdomen  is  to  be  opened  by  a  careful  dissection, 
and  if  the  incision  lead  directl}'  into  the  pus-cavity  this  is  drained  and 
washed  out  with  sterilized  water  or  a  weak  antiseptic  solution.  If,  on 
cutting  through  the  peritoneum,  no  pus  is  found,  and  the  peritoneal 
cavity  has  been  opened,  it  is  not  safe  to  evacuate  the  pus  until  the  peri- 
toneal cavit}'  has  been  shut  out  b}'  suturing  the  abscess-wall  to  the 
parietal  peritoneum,  or  packing  the  w'ound  for  a  few  days  with  iodoform 
gauze,  and  postponing  the  opening  of  the  abscess  until  firm  adhesions  have 
formed  between  the  margins  of  the  wound  and  the  surface  of  the  abscess- 
wall.  This  method  of  operating  must  be  frequentl}-  resorted  to  in  the 
treatment  of  pelvic  abscess,  abscess  of  the  liver,  and  empyema  of  the 
gall-bladder.  If  the  primary  disease  which  has  caused  the  intra-perito- 
neal  suppuration  can  be  discovered,  this  must  receive  special  attention. 
In  circumscribed  suppurative  peritonitis  in  the  right  iliac  region  caused 
\>y  perforation  of  the  appendix  vermiformis,  the  appendix  must  be  looked 
for,  and  when  found  perforated  it  is  excised  near  its  attachment  to  the 
caecum  after  tying  its  base  with  a  fine  silk  ligature ;  or,  if  this  cannot  be 
done,  it  maj-  be  slit  open  and  drained,  as  was  done  successfully  by  Tait. 


302  PRINCIPLES    OF    SURGERY. 

All  operations  for  siippnmtive  peritonitis  are  to  be  conducted  upon  rigid 
antiseptic  principles,  and  the  treatment  is  to  be  followed  without  relaxa- 
tion during  the  entire  after-treatment.  As  patients  suffering  from  peri- 
tonitis are  alw.ays  greatly  debilitated  from  the  effects  of  the  disease  as 
well  as  from  lack  of  solid  food,  which  for  well-founded  reasons  must  be 
withheld,  ever}'  eflbrt  should  be  made  to  sustain  strength  by  the  sys- 
tematic administration  of  liquid  nourishment  and  alcoholic  stimulants. 
Absolute  rest  must  be  enforced  for  the  purpose  of  limiting  the  extension 
of  the  disease  and  with  a  view  of  aiding  the  process  of  repair. 


CHAPTER  XII. 

Septicemia. 

•  Septicaemia,  septaemia,  sepsis,  are  synonymous  terms  used  to  desig- 
nate a  general  febrile  affection  caused  by  the  introduction  into  the 
circulation  of  the  products  of  fermentation  or  putrefaction,  and  which 
is  characterized  by  definite  blood-changes,  a  typical  series  of  inflamma- 
tory processes,  a  peculiar  group  of  nervous  sj^mptoms  and  critical 
discharges.  Clinically,  and  probably  etiologicall^',  it  is  closely  related 
to  pyaemia.  The  older  pathologists  entertained  the  belief  that  in  cases 
of  septicaemia  the  blood  itself  was  the  seat  of  putrefactive  changes.  At 
present  it  is  generally  conceded  that  it  results  from  the  introduction  into 
the  circulation  of  septic  micro-organisms  or  their  ptomaines.  The 
sj-mptoms  do  not  suffice  for  a  full  characterization  of  the  disease,  but 
the  specific  infection  is  the  integral  and  essential  factor. 

BACTERIOLOGICAL    RESEARCHES. 

Septic  processes  were  among  the  first  to  excite  interest  in  the  part 
played  by  micro-organisms  in  disease.  Although  some  of  the  best 
pathologists  have  been  diligently  investigating  this  subject  for  years,  we 
still  remain  in  the  dark  concerning  its  true  etiology  and  its  relation  to 
other  infective  processes.  True  sepsis  is  now  regarded  as  a  general 
infection  from  some  local  source,  unattended  by  any  gross  pathological 
changes.  Some  writers  have  claimed  the  etiological  difference  between 
septicaemia  and  p3'£emia  to  be  a  quantitative  and  not  a  qualitative  one, 
while  others  maintain  that  p3-aemia  is  a  specific  disease  sni  generis^  and 
that  it  is  in  no  wise  related  to  sepsis.  There  can  be  no  doubt  that  true 
progressive  sepsis,  if  not  invariably,  is,  at  least  frequently,  caused  bj^  the 
same  microbes  which  produce  pyaemia.  As  we  have  seen  in  the  fore- 
going chapter,  the  same  microbes,  when  introduced  into  the  peritoneal 
cavitj^  may  either  cause  a  circumscribed  suppurative  peritonitis  or  a 
diffuse  septic  peritonitis,  with  all  the  clinical  features  of  progressive 
sepsis.  The  first  reliable  investigations  into  the  microbic  origin  of 
sepsis  were  made  by  Rindfleisch  in  1866,  and,  somewhat  later,  bj'  Klebs, 
Recklinghausen,  Waldej-er,  and  Hueter.  Rindfleisch  found  bacteria  in 
abscesses,  while  the  researches  of  Klebs  initiated  a  new  era  in  the  etiology 
of  septic  diseases.     Klebs  differentiated  between  septicaemia  and  pyaemia. 

(303)  " 


304  PRINCIPLES   OF    SURGERY. 

ulllioiigli  he  eliiiined  tluit  piilrid  intoxication  and  septic  infection  were 
the  same.  In  the  tissues  altered  by  septic  processes,  and  in  the  lymph- 
spaces  and  in  the  blood,  he  found  a  microbe,  a  round  coccus,  isolated  an<l 
in  groups,  which  he  termed  mikrospoi-on  septicinn. 

Septicaemia  in  Mice. — One  of  the  best  descriptions  of  true  pro- 
gressive septiciemia  that  has  ever  been  given  is  l)y  Koch  on  septicfBinia 
in  mice.  He  used  the  same  method  which  was  followed  by  Coze,  Feltz, 
and  Davaine.  He  injected  putrid  fluids,  decomposed  blood,  putrefying 
blood,  under  the  skin  in  mice.  He  found  that  the  virulence  of  these 
fluids  was  attenuated  by  age.  Blood  that  had  putreded  onl}-  for  a  few 
da^'s,  in  5-drop  doses,  killed  a  mouse  within  a  short  time,  in  this  case 
marked  symptoms  were  observed  in  the  animal  immediately  after  the 
injection. 

The  animal  became  ver}-  restless,  running  about  constantly,  but 
showing  great  muscular  prostration  and  uncertainty  in  all  its  nu>vements; 
it  refused  food,  the  respiration  became  irregular  and  slow,  and  death 
took  place  within  eight  hours.  The  greater  portion  of  the  fluid  injected 
was  found  after  death  not  to  have  been  absorbed.  No  inflammation  at 
the  seat  of  injection.  No  macroscopical  pathological  changes  were 
found  in  any  of  the  internal  organs.  Blood  taken  from  the  right  auricle 
and  injected  into  another  mouse  produced  no  symptoms.  No  bacteria 
could  be  found  in  the  blood  or  any  of  the  internal  organs.  Koch  con- 
cluded that  death  was  not  caused  by  bacteria,  but  by  the  introduction 
into  the  circulation  of  a  preformed  poison  contained  in  the  putrid  fluid, 
as  when  smaller  doses  were  used  the  symptoms  of  intoxication  were  less 
marked,  and  when  the  quantitj^  was  reduced  to  1  drop  the  animal  often 
recovered  without  manifesting  any  morbid  symptoms.  Al)out  one-third 
of  the  animals  which  had  received  1  or  2  drops  of  the  fluid  subcutane- 
ouslj^  remained  well  for  about  twentj'-four  hours,  when  an  increased 
secretion  from  the  conjunctiva  was  observed  ;  at  the  same  time  the 
animal  showed  signs  of  great  muscular  w^eakness.  It  then  ceased  to 
take  food  ;  its  respirations  became  slower,  prostration  became  more  and 
more  marked,  and  death  came  on  almost  imperceptibly.  After  death  the 
animal  remained  in  the  sitting  posture  with  its  back  strongly  bent. 
Death  occurred  in  from  forty  to  sixty  hours  after  inoculation.  The  only 
post-mortem  change  noticed  was  a  slight  subcutaneous  oedema  at  the 
point  of  injection,  and  this  was  not  constantly  present. 

Koch  then  experimented  with  the  oedema-fluid  and  blood  of  mice 
that  had  died  of  sepsis,  ^^  drop  of  which  was  injected  into  another 
mouse,  when  exactl}'  the  same  symptoms  and  result  were  produced  in 
the  latter  animal,  after  the  same  lapse  of  time  and  in  the  same  order  as 
in  the  former. 


BACTERIOLOGICAL    RESEARCHES. 


305 


From  this  second  animal  a  third  was  infected  in  lilce  manner  witli 
identical  results  Siucessive  inoculations  proved  that  the  virus  could  be 
propagated  indefiuitel}'  from  animal  to  animal  without  losing  its  viru- 
lence.    He  could  communicate  the  disease  with  certaint}'  b}'  passing  the 


B/^V-5 


B_,.cc-v-^     ''     f~- 


'm^ 


Fig.  66.— Vein  of  the  Di.jlphragm  of  a  Septicemic  Mouse,    x  700.    (A'oc/i.)* 

A,  nuclei  of  the  vascular  wall ;  B,  septicsemic  bacilli ;  C.  white  blood-corpuscles  which  have  become  transformed 
iuto  masses  of  bacilli ;  D,  capillaries  opening  into  veiu. 

point  of  a  scalpel,   which   had  been  in  contact  with  the  infected  blood, 
over  a  small  wound  of  the  skin.     The  blood  of  the  animals  which  became 

*  F^iss.  Ot>,  67,  aiul  68  are  copied  from  '■  Traumatic  Infective  Diseases,"  by  permission  of 
the  New  Sydenham  Society,  London. 

20 


306  PRINCIPLES   OF    SURGERV. 

ill  fifter  injection  of  1  to  10  drops  of  putref)dng  blood  was  found  to 
contain,  as  a  rule,  different  varieties  of  bacteria  in  small  numbers,  micro- 
cocci, and  large  and  small  bacilli.  If,  however,  it  died  after  inoculation 
with  putrefj^ing  or  septicemic  blood,  small  bacilli  alone  appeared  in  the 
blood.  This  result  was  constant,  and  the  bacilli  were  alwavs  in  large 
numbers.  These  bacilli  lie  singly  or  in  small  groups  between  the  red 
blood-corpuscles.  One  often  can  see  the  bacilli  in  septicemic  blood 
attached  to  each  other  in  pairs,  either  in  straight  lines  or  forming  an 
obtuse  angle.  In  some  cases  Koch  has  also  seen  spores  in  the  bacilli. 
Their  relation  to  the  white  corpuscles  is  peculiar.  They  penetrate  into 
these,  and  multiply  in  their  interior. 

Microscopical  examination  of  the  tissues  at  the  point  of  inoculation 
showed  that  the  bacilli  entered  the  capillary  blood-vessels,  where  they 
caused  such  extensive  alterations  as  to  give  rise  to  extravasation  of 
numerous  red  blood-corpuscles.  They  were  never  found  in  the  l^niiphatic 
vessels.  Within  the  blood-vessels  the^^  are  almost  always  arranged  with 
their  long  axis  in  the  direction  of  the  blood-current.  In  the  capillaries 
the  bacilli  congregate,  particularly  at  the  points  of  division,  but  never 
cause  complete  obstruction.  Rabbits  and  field-mice  proved  immune  to 
inoculations  with  the  septicaemic  blood  of  the  domestic  mouse.  The 
bacillus  of  Koch's  septicaemia  can  be  cultivated  upon  a  mixture  of 
aqueous  humor  and  gelatin,  or  of  gelatin,  peptone  (1  per  cent.),  salt 
(0.6  per  cent.),  and  sodium  phosphate  in  sufficient  quantity  to  ren- 
der the  mass  alkaline  in  reaction.  The  bacilli  grow  well  upon  this 
mixture,  and  by  repeated  and  rapid  division  form  peculiar  branched 
series. 

Septicaemia  in  Rabbits. — Although  Koch  was  unable  to  produce  sep- 
ticaemia in  rabbits,  either  by  injections  or  inoculations  of  septicaemic 
products  from  the  domestic  mouse,  he  caused  the  disease  artificially  by 
injecting  a  putrid  infusion  of  meat.  In  these  cases  the  injection  pro- 
duced extensive  suppuration,  with  putrefaction,  and  the  animals  died  in 
three  days  and  a  half.  Various  bacteria  were  found  in  the  inflammatory 
product.  At  the  border  of  the  local  inflammation  the  connective  tissue 
was  infiltrated  with  a  turbid,  serous  fluid,  which  contrasted  strongly 
with  the  brownish  ofTensive  pus.  In  this  cedema-fluid  onl}^  cocci  of 
an  oval  form  were  found.  In  the  blood  similar  microbes  were  found, 
though  onl}'  in  small  numbers.  Some  of  the  small  veins  in  the 
spleen  and  kidneys  were  seen  to  be  completely  blocked  with  the  same 
microbe. 

Two  drops  of  the  oedema-fluid  were  injected  under  the  skin  of  the 
back  of  a  second  rabbit.  The  animal  died  in  twenty-two  hours,  and 
here,  in  the  vicinity  of  the  injection,  not  a  trace  of  suppuration  could  be 


BACTERIOLOGICAL    RESEARCHES. 


307 


found.  Hsemoniiagic  extravasations  were  found  in  the  inflamed 
oedematous  connective  tissue.  No  alterations  were  found  in  the  heart 
and  lungs.  In  this  animal  the  oval  micrococci  were  alone  present 
in  the  oedema-fluid.  Micrococci  were  also  found  in  the  capillary  ves- 
sels in  different  organs  ;  in  some  of  them  the  lumen  of  the  vessels 
was  completel}'   blocked.      In    the   capillary   vessels    surrounding   the 


A-- 


t 


^J 


e 


© 


Fig.  67.— Glomerttltjs  OF  A  Septicemic  Rabbit.    x700.    {Koch.) 

A,  capillary  loop  with  oval  micrococci  spread  out  like  a  membrane  ;  B,  micrococci  deposited  on  the 
walls  of  a  capillary  vessel ;  0,  loop  completely  filled  with  micrococci;  D,  individual  micrococci  in  a 
eapillary  vessel  near  a  glomevnlus. 


intestinal    glands    numerous    obstructing    masses    of    the    bacilli    were 
present. 

At  many  points  these  were  so  extensive  that  branching  accumula- 
tions were  seen  consisting  entirelv  of  these  organisms.  This  microbe 
was  never  seen  to  inclose  blood-corpuscles,  and,  as  they  did  not  cause 
coagulation  of  the  blood,  embolism  was  never  observed.  The  virulence 
of  the  bacillus  was  not  increased  by  successive  inoculation  with  infected 


308 


PRTNCTPLES    OF    SURGERY. 


1)loocl  from  iiiiimal  to  aniuuil.  The  bacillus  now  under  consideration  ap- 
pears to  be  closel}'  allied  or  identical  with  that  of  Davaine's  septicaemia, 
■which  was  first  produced  b}^  injecting  rab1)its  with  putrid  ox-blood.  The 
two  diseases  are  distinguished  in  that  Davaine's  septicaemia  is  easily  trans- 
missible to  guinea-pigs,  but  not  to  birds;  while  mice,  pigeons,  fowls,  and 
sparrows  are  very  susceptible  to  the  bacillus  of  septicsemia  in  rabbits, 
discovered  by  Koch,  but  guinea-pigs,  dogs,  and  rats  resist.  Hueppe  be- 
lieves that  this  microbe  is  not  a  bacillus,  but  a  coccus  in  a  state  of  elonga- 


FiG.  68.— Capillary  Vessels  Surrounding  the  Intestinal  Glands  op  a 
Septicemic  Rabbit.    X700.    {Koch.) 


tion;  and  Gaffky,  Schuetz,  Kitt, Salmon,  Fluegge,and  Baumgarten classify 
it  with  the  bacilli.  It  readily  stains  in  aniline  solutions.  Upon  sterilized 
gelatin  it  grows  in  the  form  of  clear,  finely-granular  drops,  which,  wdien 
they  become  confluent,  form  a  culture  which  appears  as  a  gra3'ish-white 
film  with  jagged  borders.  Liquefaction  of  the  gelatin  never  takes  place. 
It  can  also  be  cultivated  upon  agar-agar,  coagulated  blood-serum,  and 
potato.  Gaffky  investigated  Davaine's  septicaemia  experimentally.  He 
procured  the  infection  by  using  water  from  a  stagnant  rivulet,  and,  bj' 
continually    controlling   the   experiments    with   the   microscope,   using 


BACTERIOLOGICAL    RESEARCHES.  309 

Koch's  methods,  and  working  only  with  pure  cultures,  he  was  able  to 
prove  be3ond  a  doubt  that  the  theories  of  progressive  virulence  of  bac- 
teria were  untenable.  He  showed  that  the  highest  degree  of  virulence 
was  already  attained  in  the  second  generation.  He  pointed  out  that  the 
fallacious  conclusions  were  due  to  impurification  in  the  experiments,  and 
that  when  the  proper  precautions  are  taken,  in  the  process  of  steriliza- 
tion, to  prevent  the  admixture  of  other  micro-organisms,  the  introduc- 
tion of  one  kind  alwa3's  produces  in  the  same  animal  the  same  definite 
result. 

The  most  interesting  conclusions  to  be  drawn  from  the  experi- 
ments in  Koch's  laboratory  point  to  the  fact  that  septicaemia  is  only 
a  general  term  which  includes  a  number  of  morbid  processes,  and  this 
is  well  illustrated  by  the  injection  into  the  tissues  of  the  "  vibriones  sep- 
tiques  "  of  Pasteur.  Surface  inoculations  with  these  bacilli  produce  no 
eflTect ;  their  pathogenic  influence  became  only  evident  after  injections  into 
the  subcutaneous  connective  tissue.  Gatfky  found  that  this  bacillus 
A  B  grows  most  readih^  upon  potato.  Koch 

applied  to  the  condition  produced  b}' 
\         this    bacillus    the    tei'm   "  malignant 
\      oedema." 


V 


/ 1 


7  ^ 


Fig.  69.— Bacillus  of  Malig>'axt  CEdema. 

X700.     (Koch.)  ^        „„     . 


Malignant  (Edema. — The  bacillus  of  malignant  oedema  was  de- 
scribed b}'  Koch  as  the  cause  of  a  fatal  disease  in  guinea-pigs  and  rab- 
bits. The  same  bacillus  was  described  b}'  Pasteur  as  "  vibrion  septique." 
Recently,  this  disease  has  been  found  also  in  some  of  the  domestic  mam- 
malia and  in  man.  The  bacillus  resembles  morphologically  the  bacillus 
anthracis. 

Usually,  two  or  three  bacilli  are  joined  end  to  end,  and  thus  form 
straight  or  curved  rods  two  or  three  times  the  length  of  one  bacil- 
lus. When  stained,  the  threads  present  a  granular  appearance,  from  the 
unequal  distribution  of  the  staining  material. 

This  bacillus  is  somewhat  narrower  than  the  anthrax  bacillus,  and 
when  stained  does  not  present  such  a  regular,  chain-like  appearance. 
Sometimes  the  bacillus  is  found  motile,  but  not  alwa^'S,  while  the  anthrax 
bacillus  is  always  devoid  of  this  propert}-.  It  multiplies  by  spores,  but 
these  appear  only  in  the  middle  and  at  the  ends. 


310 


PRINCIPLES    OF    SURGERY. 


This  microbe  is  juuierobic,  and  enii  oiil}'  be  cultivated  by  exclusion 
of  oxygen.  The  bacillus  can  only  grow  in  the  interior  of  agar-agar, 
gelatin,  or  coagulated  blood-serum,  if  the  needle-puncture  on  the  sur- 
face of  the  nutrient  medium  is  hermetically  sealed.  The  growth  of  the 
bacillus  is  attended  by  the  formation  of  gas-l)ubbles. 

The  gas  has  an  intensely-  offensive  odor.  Blood-serum  is  liquefied. 
The  temperature  of  the  blood  is  most  favorable  to  the  grow'th  of  the 
bacillus,  and  cultures  develop  also,  but  slowly,  at  a  temperature  of 
18°  to  20°  C. 

This  bacillus  is  widely  diffused,  and  can  be  found  in  almost  any 
putrefying  substance.  The  bacillus  of  malignant  oedema  possesses  the 
power  of  peptonizing  albumen.  It  is  found  in  abundance  in  garden- 
earth  and  hay-dust.  If  a  small  quantity  of 
either  of  these  substances  is  inserted  un- 
derneath the  skin  of  a  guinea-pig,  death  is 
produced  within  forty-eight  hours.  The 
most  characteristic  post-mortem  appearance 
is  a  diffuse  oedema  at  the  point  of  inocula- 
tion. The  oedema-fluid  is  a  clear,  reddish 
serum,  in  which  can  be  found  bubbles  of 
gas  and  numerous  bacilli.  The  spleen  is 
enlarged,  of  a  darker  color  than  normal, 
but  the  other  organs  present  no  macroscopi- 
cal  changes.  The  bacilli  can  be  found  in 
the  parenchj'ma-fluid  of  nearlj^  all  organs, 
and  especially  is  their  number  great  in  the 
envelopes  of  the  infected  organs.  Mice  die 
in  from  sixteen  to  twenty  hours  after  inocu- 
lation. Horses,  sheep,  and  pigs  can  be  suc- 
cessfully inoculated,  while  cattle  are  immune  to  the  bacillus.  The 
disease  can  be  communicated  from  animal  to  animal  b}^  implantation 
of  fragments  of  infected  tissue  or  b}^  inoculation  with  1  or  2  drops  of 
the  oedema-fluid.  Surface  inoculation  is  harmless,  as  the  bacillus  will 
not  multipl3'  when  exposed  to  atmospheric  air.  In  man  malignant 
oedema  appears  in  the  form  of  progressive  gangrene  with  emphysema 
(gangrene  gazeuse).  Recently,  the  identity  of  this  disease  with  malig- 
nant oedema  has  been  proved  by  inoculation  experiments  by  Chaveau, 
Arloing,  Brieger,  and  Ehrlich.  Animals  which  have  recovered  from  an 
attack  of  malignant  oedema  remain  immune  to  this  disease,  but  prophy- 
lactic inoculations  have  so  far  yielded  only  negative  results.  Chaveau 
made  man}-  experiments  on  guinea-pigs,  sheep,  and  horses  by  injecting 
the  liquid  contents  of  bullse  which  he  found  in  cases  of  septic  gangrene. 


Fig.  71.— IJULTUKES  of  Bacillus 
OF  Malignant  CEdeima  in 
Gelatin.    (Fluegge.) 


PYOGENIC    MICROBES    AS    A    CAUSE    OF    SEPSIS.  311 

In  doses  of  ^  drop  in  guinea-pigs  and  from  2  to  4  drops  in  horses,  it 
produced  death  in  a  short  time.  In  all  cases  the  necrops3- showed,  at 
the  point  of  injection,  localized  oedema  and  turbid  serum  in  the  perito- 
neal, pleural,  and  pericardial  cavities.  In  the  fluids  the  bacillus  could 
alwaj^s  be  demonstrated  under  the  microscope.  The  disease  could  be 
reproduced  in  other  animals  b\'  inoculation  with  the  serous  fluid  con- 
tained in  an}'  of  the  serous  cavities.  The  microbe  proved  less  A-irulent 
when  injected  directh'  into  the  circulation. 

PYOGENIC    MICROBES    AS   A    CAUSE   OF    SEPSIS. 

The  general  symptoms  which  accompan}-  all  suppurative  affections 
represent,  etiologically  and  clinicall}^,  a  form  of  sepsis,  which  differs  in  its 
intensity  according  to  the  quantitj'  of  pus-microbes,  or  their  ptomaines, 
which  reach  the  general  circulation.  The  slight  fever  which  often 
attends  the  development  of  a  furuncle  ceases  with  the  removal  of  the 
products  of  inflammation,  while  a  septic  or  diff'use  suppurative  perito- 
nitis results  in  death  in  a  short  time  from  septic  infection.  The  different 
forms  of  suppurative  inflammation  result  in  gangrene  if  the  disease 
prove  fatal ;  the  immediate  cause  of  death  is  usually  septic  infection  or 
putrid  intoxication.  Watson  Che3'ne  maintains  that  the  microbes  of 
sepsis  only  grow  in  loco,  and  act  by  producing  toxic  ptomaines,  or,  if 
they  occur  in  the  blood,  the}'  do  not  make  emboli, 

Yidal  reported  to  the  Academie  de  Medecine  de  Parisihe  results  of 
his  studies  of  the  "  forme  septicemique  pure "  in  puerperal  fever  of 
typhoid  type  without  suppuration.  In  all  of  the  cases  in  which  he  made 
a  bacteriological  examination  he  found  the  streptococcus  pyogenes,  and 
from  this  and  the  results  of  his  culture  and  inoculation  experiments  he 
comes  to  the  conclusion  that  it  is  impossible,  in  the  present  state  of  our 
knowledge,  to  distinguish  between  the  various  forms  of  streptococci, and 
that  one  and  the  same  kind  can  set  up  any  of  the  various  forms  of  septic 
infection.  Besser  has  examined  22  cases  of  traumatic  sepsis,  and  found 
microbes  of  suppuration  in  cA^er}^  one  of  them.  During  the  patient's 
life  he  discovered  the  microbe  (a)  in  the  blood  in  4  of  16  cases  exam- 
ined ;  {h)  in  the  pus  or  fluid  discharge  from  the  primary  focus,  in  IT  of 
17;  (c)  in  the  urine,  in  3  of  4  ;  and  (d)  in  the  sputa,  in  3  of  3  ;  while 
after  death  the  micro-organism  was  present  (a)  in  the  blood,  in  T  of  15  ; 
(6)  in  the  internal  organs,  in  10  of  18  ;  and  (c)  in  the  pus  or  uterine  dis- 
charges, in  12  of  12.  In  6  of  22  cases  pus-microbes  were  simultane- 
ously detected  side  by  side  with  masses  of  bacteria  of  many  other 
species.  In  3  cases,  however,  the  streptococcus  was  found  alone,  unasso- 
ciated  with  any  other  microbe.  Besser  is  of  the  opinion  that  the  strep- 
tococcus of  suppuration   is  the  most  frequent  cause  of  sepsis.     Smith 


312  PRINCIPLES    OF    SURGERY. 

isolated  and  cultivated,  from  2  cases  of  puerperal  sepsis,  a  streptococcus 
vvhioh,  by  inoculation  and  cultivation  experiments,  differed  from  the 
streptococcus  of  Fehleissen  and  the  ordinary  streptococcus  of  suppura- 
tion. He  made  a  series  of  gelatin  cultures  with  blood  taken  from  the 
heart.  After  an  interval  of  two  or  thi'oe  days  numerous  colonies 
appeared.  Rats  inoculated  with  a  pure  culture  died  in  from  tliree  to 
four  days  ;  the  same  microbe  was  discovered  in  their  l)lood.  Inoculations 
were  also  made  in  the  ears  of  rabbits,  and  at  the  end  of  twent3-four 
hours  a  circumscribed  redness  without  tendency  to  ditfusion  was  appar- 
ent, the  redness  disappearing  in  two  or  three  da3s.  Anotlier  series  of 
cultures  and  inoculations  was  made  with  blood  taken  from  the  finger  of 
a  woman  sick  with  puerperal  fever,  with  similar  results. 

From  these  considerations  it  becomes  evident  that  the  essential  bacterial 
cause  of  septicaemia  is  variable^  and  that  the  disease  rejiresents  a  general 
febrile  condition,  ivhich  is  brought  about  by  the  absorption  from  a  local 
focus  of  different  toxines  from  as  many  different  microbes.  As  the  in- 
troduction into  the  circulation  of  the  products  of  putrefaction  is  fol- 
lowed by  a  complexus  of  symptoms  which  closely  resembles  what  is 
understood  clinically  by  the  term  septicaemia,  and  as  different  microbes 
have  been  cultivated  from  septic  patients,  it  would  seem  that  this  disease 
can  be  produced  by  any  of  the  microbes  which,  after  their  introduction 
into  the  organism,  have  the  capacity  to  produce  a  sufficient  quantity  of 
phlogistic  ptomaines  to  give  rise  to  septic  intoxication. 

CLINICAL   FORMS   OF    SEPTICEMIA. 

A  clinical  description  of  septicaemia  cannot  be  given  without  a  sub- 
division of  the  disease  upon  an  etiological  basis.  Since  the  publication 
of  Gaspard's  researches  it  is  absolutely  necessary  to  make  a  distinction 
between  septic  intoxication  and  septic  infection.  Bv  septic  intoxication 
is  understood  that  form  of  septicaemia  which  is  caused  b}-^  the  absorption 
from  a  local  focus  of  a  ferment  or  the  products  of  putrefaction,  while  the 
term  septic  infection  is  limited  to  those  cases  where  septic  micro-organ- 
isms gain  entrance  into  the  circulation,  and  not  only  exercise  their  patho- 
genic properties  in  the  blood,  but  retain  their  capacity  of  reproduction 
in  the  circulation  and  distant  organs.  Septic  intoxication  is  caused  by 
the  absorjMon  of  a  preformed  ferment  or  toxine,  which  produces  the 
maximum  result  as  soon  as  it  reaches  the  circulation,  and  the  symptoms 
subside  with  the  arrest  of  further  supjjly  and  the  elimination  tf  the  septic 
material  from  the  circulation.  Sepdic  infection, on  the  other  hand,  occurs 
in  consequence  of  the  introduction  into  the  circulation  of  living  micro- 
organisms which  multiply  with  great  rapidity  in  the  blood, — a  circum- 
stance which  imparts  to  this  form  of  septicaemia  its  progressive  character. 


CLINICAL    FORMS    OF    SEPTICEMIA.  313 

Septic  intoxication  is  caused  either  by  the  absorption  of  fibrin  ferment  or 
the  products  of  putrefactive  bacteria. 

(a)  Fermentation  Fever. — Fermentation  fever  (Bergmann),  after-fever 
^^Billruth),  aseptic  fever  (^Yolkmann),  resorption  fever,  are  terms  used  to 
designate  a  general  febrile  disturbance  caused  by  the  absorption  of  the 
products  of  aseptic  tissue  necrosis.  This,  the  most  simple  and  harmless 
of  all  wound  complications,  appears  as  a  temporarj-  fever  soon  after  an 
injury  or  operation,  and  is  caused  by  the  absorption  of  aseptic  phlogistic 
substances.  Different  aseptic  inert  substances,  when  injected  into  the 
circulation,  are  known  to  produce  a  rise  in  temperature.  Bei'gmann  wit- 
nessed such  a  reaction  after  intra-venous  infusion  of  a  physiological  solu- 
tion of  salt;  Freese,  after  transfusion  of  blood  of  healthy  animals;  and 
Bergmann,  Strieker,  Albert,  and  Billroth,  after  intra-venous  injections  of 
a  considerable  quantity  of  well-water.  The  same  effect  is  produced  b}^ 
intra-venous  injections  of  water  in  which  fine  foreign  particles,  as  flour 
or  finely-puh^erized  charcoal,  are  suspended.  Yolkmann  and  Genzmer 
observed  a  rise  in  temperature  in  patients  soon  after  the  operation  was 
completed  and  when  the  wound  remained  aseptic  throughout,  and  hence 
called  this  form  of  fever  aseptic  fever.  These  authors  attribute  the  fever 
to  the  reception  into  the  blood  of  dead  tissue  material.  Bergmann 
devised  the  terra  fermentation  fever  upon  the  theory  that  the  fever  is 
caused  b3'  the  presence  of  fibrin  ferment  in  tlie  blood. 

Augerer  and  Edelberg  demonstrated  experimentally  that  this  fever 
occurs  after  transfusion,  if  the  blood  transfused  contain  fibrin  ferment. 
Schmiedeberg  attributed  the  fever  to  the  presence  of  another  blood  fer- 
ment which  he  discovered  and  whicli  he  called  "  histozym."  Bergmann 
and  Augerer's  experimental  researches  show  that  a  fever  which  resem- 
bles the  fermentation  fever  almost  to  perfection  can  be  artificially  pro- 
duced in  animals  by  intra-venous  injections  of  pancreatin,  pepsin,  and 
trypsin.  It  would  appear  that  the  albuminoid  substances,  which  are  in 
excess  in  the  blood,  undergo  oxidation  by  the  action  of  a  ferment,  and 
that  the  chemical  changes  brought  about  in  tbis  manner  occasion  rise  in 
temperature,  while  the  products  of  oxidation  are  eliminated  tlirough  the 
kidneys.  Riedel  found,  in  man}'  cases  of  simple  subcutaneous  fracture, 
albumen  in  tlie  urine  during  the  first  three  or  four  days,  and  the  urine 
alwaj'S  contained  brown  masses,  which  he  regarded  as  products  of  the  red 
blood-corpuscles.  Worm  Miiller  found  invariably,  after  transfusion  of 
blood,  a  considerable  increase  of  urates  in  the  urine.  The  occurrence  of 
fever  after  the  introduction  of  foreign  aseptic  substances  into  tlie  cir- 
culation, can  only  be  explained  upon  the  supposition  that  they  destroy 
red  nnd  white  corpuscles  in  the  blood,  and  that  in  this  manner  fibrin 
ferment,  the  cause  of  the  fever,  is  generated. 


314  PRINCIPLES   OF    SURGERY. 

Symptoms  and  Diagnosis. — Fermentation  fever  is  prone  to  follow  an 
oi)eratioii  or  injury  if  antiseptic  solutions  are  allowed  to  remain  in  the 
wound,  tliereby  causing  necrosis  of  the  superficial  tissues,  or  where,  after 
closure  of  the  wound,  parenchymatous  oozing  gives  rise  to  tension, — a 
local  condition  which  forces  the  products  of  coagulation  necrosis  into 
the  circulation.  As  not  all  extravasations  of  blood  give  rise  to  fever, 
we  must  take  it  for  granted  that  when  fever  is  not  produced  its  absence 
is  owing  eitlu^r  to  an  absence  of  fibrin  ferment  or  the  existence  of  local 
conditions  which  prevent  its  absorption.  From  my  own  observations  I 
am  convinced  that  the  amount  of  extravasated  blood  holds  no  relation 
whatever  to  tlie  frequency  of  its  occurrence  or  its  intensity.  A  small 
extravasation  under  high  pressure  is  more  frequently  the  cause  of  fermen- 
tation than  a  large  blood-clot  in  a  location  less  favorable  to  the  absorp- 
tion of  librin  ferment.  Fermentation  fever  makes  its  appearance  within  a 
few  hours  after  an  injury  or  operation,  and,  as  a  rule,  it  is  not  preceded 
b}'  a  chill.  The  temperature  rapidly  reaches  its  maximum,  which  varies 
from  100°  to  104°  F.,  and  remains,  without  much  variation,  in  the 
vicinit}'  of  the  maximum  height,  to  drop  suddenly  to  normal  at  the  end 
of  the  first  to  the  third  da3^  The  pulse  is  correspondingly  increased  in 
frequency  during  the  febrile  attack.  The  sensorium  remains  intact,  the 
appetite  is  not  much  disturbed,  and  none  of  the  subjective  symptoms  are 
proportionate  to  the  severity  of  the  febrile  disturbance.  Patients  with 
a  high  temperature  feel  so  well  that,  if  their  wounds  permit  it,  they  will 
insist  in  walking  around  and  will  attend  to  their  business,  contrary  to  the 
advice  of  the  attending  surgeon.  The  most  important  diagnostic  features 
of  fermentation  fever  are  its  early  onset  after  an  injury  or  operation, 
and  its  spontaneous  subsidence  in  from  one  to  three  days.  As  the 
disease  is  caused  by  the  introduction  of  phlogistic  substances  from  a 
local  focus,  and  propagated  by  intra-vascular  chemical  changes,  it  is 
uninfluenced  by  any  form  of  medication.  The  fever  subsides  sponta- 
neously upon  cessation  of  the  primary  cause,  and  with  the  elimination 
through  the  kidneys  of  the  products  of  intra-vascular  chemical  changes. 
As  the  remaining  forms  of  sepsis  usuall3'  appear  at  a  time  wdien  fermen- 
tation fever  has  run  its  course,  the  differential  diagnosis  presents  no 
great  difficulties. 

The  treatment  of  fermentation  fever  is  entirely  of  a  prophylactic 
nature.  The  prophylactic  measures  consist  in  a  careful  ha^mostasis,  and 
in  cases  where  parenchymatous  oozing,  from  the  nature  of  a  wound  or 
the  anatomical  structure  of  the  tissues,  is  to  be  expected,  the  prevention 
of  the  accumulation  of  the  primar3'  wound-secretion  by  eflficient  drainage. 
Fermentation  fever  must  be  included  among  the  septic  diseases,  as  the 
fibrin  ferment  acts  as  a  toxic  substance  in  the  same  manner  as  the  toxines 


CLINICAL    FORMS   OF    SEPTICEMIA.  315 

elaborated  by  septic  micro-organisms.  Future  research  maj'  yet  demon- 
strate that  even  this,  the  most  harmless  form  of  septicaemia,  is  not  an 
aseptic  fever,  but  that  it  is  caused  b}^  pathogenic  micro-organisms,  either 
too  few  in  number  or  not  of  sufficient  potency  to  produce  the  graver 
forms  of  the  disease. 

(b)  Sapraemia. — Tliis  word  was  devised  by  Mathews  Duncan  to  include 
a  form  of  se[)ticffimia  resulting  from  the  absorption  of  the  products  of 
putrefaction.  Sapraemia  is  the  typical  form  of  septic  intoxication,  as  it 
is  always  caused  by  the  introduction  into  the  circulation  of  preformed 
toxines  or  ptomaines  elaborated  in  dead  tissues  b}'^  putrefactive  bacteria. 
It  is  closely  allied  to  fermentation  fever,  as  the  S}' mptoms  are  never  in- 
tensified after  the  removal  of  the  primarj^  cause,  but,  as  a  rule,  subside 
promptly-  after  this  has  been  accomplished.  As  sapraemia  never  occurs 
without  putrefaction  of  necrosed  tissue,  and  as  putrefaction  never  takes 
place  without  infection  with  putrefactive  bacteria,  it  becomes  necessary 
1  to  consider  briefly  the  micro-organisms  which  are 

Icuowii  to  cause  the  clinical  forms  of  putrefaction. 


•»>  9S^ 


^/l  Y^^  2  3 

FiQ.  72.  Fig.  73.  Fig.  74. 

Figs.  72,  73,  and  74.— Bacillus  Saprogenes  1,  2,  3.    962  :1.    {Rosenhach.) 

Bacilli  of  Putrefaction. — The  bacilli  of  putrefaction  exercise  their 
liatliogenic  qualities  onl^-  in  dead  tissue  exposed  to  the  atmospheric 
air.  Clinically  the}'  are  therefore  present  in  the  products  of  coagulation 
necrosis,  or  as  a  secondary  infection  in  tissues  destroyed  b}- other  micro- 
organisms. Most  of  them  possess  gasogenic  properties.  Rosenbach 
discovered,  in  different  fetid  secretions,  three  forms  of  bacilli  which  he 
designated  respectiveh'  bacillus  saprogenes  1,  2,  3. 

Bacillus  Saprogenes  1. — A  comparatively  large  bacillus,  which  mul- 
tiplies by  end  spores,  which,  however,  grow  only  from  one  end  of  the 
bacillus. 

On  nutrient  agar-agar  the  bacillus  grows  in  the  form  of  an  irregular 
sinuous  streak,  with  a  mucilaginous  appearance.  The  bacilli  grow 
readil}'  also  in  blood-serum,  and  all  cultures  emit  the  odor  of  decom- 
posing kitchen  refuse.  Albumen  or  meat  acted  upon  b}-  a  culture  of  this 
bacillus  undergoes  rapid  putrefaction  if  exposed  to  atmospheric  air,  but 
if  air  is  excluded  the  action  of  the  microbes  upon  these  substances  is 
very  slight.  Cultures  injected  into  healthy  tissues  and  joints  are 
harmless. 


316  PRINCIPLES   OF    SURGEliY. 

Bacillus  Saprogenes  J. — This  bacillus  was  isolated  by  Rosenbach 
from  fetid  sweat.  The  rods  are  shorter  and  thinner  than  the  preceding 
ones. 

This  bacillus  develops  very  rapidly  on  agar-agar,  forming  transparent 
drops,  Avhich  become  gray.  The  culture  yields  a  characteristic  fetid 
odor,  similar  to  the  last.  Cultures  of  this  bacillus  injected  into  the 
knee-joint  and  pleural  cavity  of  rabbits  caused  acute  suppurative 
inflammation  and  death. 

Bacillus  Saprogenes  3. — This  bacillus  was  discovered  by  Rosenbach 
in  the  pus  of  2  cases  of  osteomyelitis  with  septic  manifestations 
comi)licating  compound  fracture. 

Cultivated  on  nutrient  agar-agar,  an  ash-gray,  almost  liquid  culture 
is  developed,  with  a  strong,  characteristic  odor  of  putrefaction.     Injected 


Fig.  75.— Proteus  Vulgaris.    285:1.    Swarming  Islets.    (Hauser.) 

into  the  knee-joint  or  abdomen  of  a  rabbit,  an  opaque,  yellowish-green 
infiltration  resulted. 

Proteus  Vulgaris. — This  and  the  following  species  have  been  recently 
described  by  Hauser  as  present  in  putrefying  meat-infusions,  and  as 
being  intimately  connected  with  the  process  of  putrefaction.  As  the 
name  indicates,  these  bacteria  are  capable  of  changing  their  form  during 
their  development.  Thedifterent  species  of  proteus  have  been  described 
as  coccoid,  bacteroid,  spindle-shaped,  and  spiralinar,  on  account  of  the 
ever-changing  form  the}'  assume  during  their  growth.  In  proteus  vul- 
garis the  bacteria  vary  greatly  in  size. 

Many  of  the  rods  are  actively  motile,  and  cultivated  upon  nutrient 
gelatin  they  convert  it  into  a  turbid,  gr:i3'ish-white  liquid.  If  cultivated 
in  a  capsule  containing  5  per  cent,  of  nutrient  gelatin,  a  few  hours  after 
inoculation,  the  most  characteristic  movements  of  the  individual  bacilli 


CLINICAL   FORMS   OF    SEPTICEMIA. 


mi 


are  observed  on  the  surface  of  the  gehitiii,  although  at  this  early  stage 
no  liquefaction  can  be  detected.  The  movements  are  not  observed  if 
the  nutrient  medium  contains  10  per  cent,  of  gelatin.  Spore  formation 
was  never  observed.  Injected  subcutaneously  in  small  doses,  no  results 
were  obtained ;  larger  doses  sometimes  caused  circumscribed  abscess  at 
the  point  of  injection.  Intra-venous  injection  of  a  large  dose  produced 
toxic  sj-mptoms  in  rabbits  and  guinea-pigs,  and  these  were  not  modifietl 
by  .using  the  filtrate  of  a  liquefied  culture,  showing  that  the  toxic  sub- 
stance was  held  in  solution. 

Proteus  Mirabilis. — Rods  varying  greatlj-  in  length,  sometimes  so 
short  that  they  appear  like  cocci,  at  others  of  considerable  length. 

The  rods  occur  singl}-  and  in  zodglcea,  and  sometimes  in  tetrads, 
pairs,  chains,  or  as  short  rods  in  twos, 
resembling  bacterium  termo, — in  fact, 
in  all  conceivable  transition  forms. 

Cultivated  on  nutrient  gelatin 
they  form  a  thick,  whitish  laj-er,  in 
concentric  circles,  which  in  time  lique- 
fies the  medium.  Similar  movements 
are  observed  in  capsule-cultivations 
as  with  proteus  vulgaris.  The  patho- 
genic properties  of  the  mirabilis  are 
the  same  as  those  of  vulgaris. 

Proteus  Zenker!. — Rods  about 
four  times  as  long  as  wide,  in  two, 
like  bacterium  termo.  Cultivated  on 
nutrient  gelatin  no  liquefaction  re- 
sults, but  a  thick,  whitish-gra}^  layer 
is  formed,  with  sloping  margins.  The 
bacilli  are  motile,  and  the  same  phe- 
nomena are  observed  on  the  solid  medium  as  in  the  other  forms.  Spirilli 
and  spiralinar  forms  are  seldom  seen.  Gelatin  and  blood-serum  cultures 
emit  no  fetid  odor,  but  meat-iu fusion  undergoes  rapid  putrefaction  and 
yields  the  usual  fetid  odor.  The  pathogenic  qualities  are  the  same  as 
those  of  the  other  species  of  proteus. 

As  the  microbes  of  putrefaction,  which  have  first  been  described, 
possess  limited  or  no  pathogenic  qualities  when  introduced  into  health}^ 
tissue,  it  is  evident  that  their  toxic  effect  is  caused  bj'  a  soluble  substance 
which  they  produce  when  they  find  their  way  into  dead  tissue  exposed  to 
atmospheric  air.     This  leads  us  to  a  consideration  of  the 

Ptomaines. — Ptomaine  is  a  term  used  to  designate  certain  toxic 
substances  (resembling  alkaloids)  which  are  produced  during  the  process 


Fig.  76.— Pkotetjs  Mieabii.is, 
Swarming  Islets.    (Hauser.) 


285:1. 


318  I'KINCIPLES   OF    SURGERY. 

of  putrefaction.  Gautier  li:is  shown  that  in  dead  animal  tissues  proc- 
esses of  putrefactive  decomposition  set  in,  by  which  certain  alkaloids 
are  elaborated  from  alljiimiiious  substances,  which  have  I)een  called 
ptomaines  bv  Selmi.  In  the  latter  part  of  the  seventeenth  century 
Klrcher  and  Leuwenhoek  claimed  that  putrid  su])st:inces  contained 
minute  microscoi)ical  worms,  which  caused  the  putrefaction.  In  1820 
Kerner  pointed  out  the  resemblance  between  the  symptoms  of  poisoning 
by  sausages  and  by  atropine.  He  was  thus  the  first  to  raise  the  sus- 
picion that  toxic  alkaloids  were  formed  through  the  decomposition  of 
albumen.  In  1856  I'anum  sliowed  that  tlie  inflammatory  change  which 
occurs  in  the  intestinal  mucous  membrane  of  animals  fed  on  putrid 
infusions  is  due  to  a  chemical  poison,  which  remained  unaffected  b}' 
boiling  for  a  long  time  ;  and  his  conclusion  that  the  toxic  substance 
contained  in  putrid  fluids  was  of  a  chemical  nature  was  confirmed  b}'' 
Weber,  Hemmer,    Schweninger,  Stich,  and    Thiersch.     In    1875  W.  B. 


/ 


Fig.  77.— Involution  Forms  of  Proteus  Mirabilis.    524  : 1.    (Hauser.) 

Richardson  isolated  a  toxic  substance,  which  he  called  "  septine,"  from 
the  inflammatory  transudation  in  the  peritoneal  cavity  of  a  person  that 
had  died  of  pyaemia.  With  this  substance  he  successfully  infected 
animals.  He  also  found  that  this  substance  could  be  made  to  combine 
with  acids,  so  as  to  form  salts,  without  losing  its  toxic  qualities.  Berg- 
mann  and  Schmiedeberg  isolated  a  crystalline  poison  from  decomposing 
yeast,  to  which  they  gave  the  name  of  "sepsin."  This  substance,  when 
injected  into  the  subcutaneous  tissue  or  venous  circulation  in  animals, 
produced  well-marked  symptoms  of  septic  intoxication  ;  the  intensity  of 
the  symptoms  were  found  to  vary  with  the  amount  of  the  substance  in- 
jected. Zuelzer  and  Sonnenschein  obtained,  from  macerated  dead  bodies 
and  from  putrid  meat-infusions,  small  quantities  of  a  crystallizable  sub- 
stance which  exhibited  the  reactions  of  an  alkaloid,  and  had  a  physio- 
logical action  like  atropine,  dilating  the  pupil,  paralyzing  the  muscular 
fibres  of  the  intestine,  and  increasing  the  rapidity-  of  tiie  pulse.  In 
1857,  Pasteur  made  the  important  discover3-  that  specific  micro-organisms 


CLINICAL    FORMS    OF    SEPTICEMIA.  '^\9 

are  the  cause  of  the  various  forms  of  fermeutation  and  putrefaction. 
No  discover}-,  perhaps,  attracted  such  universal  attention  as  Pasteur's 
theor}'  of  fermentation.  This  theory  was  strengthened  somewhat  later 
by  Lemaire's  observation,  that  all  fermentative  changes  in  fluids  are  sus- 
pended on  the  addition  to  the  fluids  of  phenic  acid,  from  which  he 
concluded  that  fermentation  must  be  due  to  living  organisms.  Next 
came  tiie  care  fully -conducted  experiments  of  Lister,  who  showed  that  air 
is  deprived  of  its  action  in  causing  putrefaction  of  organic  substances 
if  it  is  passed  through  a  filter,  or  if  the  fluids  are  placed  in  on  open  vessel 
with  the  mouth  of  the  vessel  so  arranged  that  dust  cannot  reach  the 
fluid  b}'  gravitation. 

Lister's  great  life-worlc,  antiseptic  surgery,  that  has  created  a  new 
epoch  in  the  histor}-  of  medicine  and  surger^^,  is  based  upon  what  then 
was  still  a  theor}',  that  inflammation,  suppuration,  and  septic  infection 
of  wounds  are  caused  by  living  specific  micro-organisms.  Selmi  discov- 
ered ptomaines  in  an  exhumed  bodj',  in  18T2.  The  ptomaines  isolated 
b}'  him  were  volatile  alkaloids.  Gautier,  independently  of  Selmi,  and 
about  the  same  time,  made  the  same  observations,  but  believed  that  the 
toxic  substances  were  volatile,  and  that  in  their  action  they  resembled 
the  narcotics,  morphia  and  atropia,  and  were  more  nearl}'  allied  to  the 
alkaloid  extracted  from  poisonous  mushrooms. 

Semmer  gives  an  account  of  the  action  of  septic  substances  as 
studied  experimentally  by  Guttmann,  of  Dorpat.  The  experiments  were 
made  with  putrid  substances,  products  of  inflammation,  septic  blood, 
and  cultivations  of  septic  bacteria.  These  researches  showed  that  a 
chemical  poison  is  formed  in  putrefying  substances,  and  that  a  certain 
qnantit}'  of  such  poison  produces  S3'mptoms  of  sepsis  and  death  in 
animals.  Tlie  blood  of  animals  killed  with  such  putrid  poisons  was 
found  to  possess  no  infective  qualities,  and  the  usual  putrefactive  bac- 
teria were  destroyed  in  the  blood,  and  only  appear  again  after  the  death 
of  the  animal.  It  was  claimed,  even  at  that  time,  that  the  bacteria 
elaborate  the  poison,  as  experiments  made  with  cultures  grown  outside 
the  body  produced  the  same  effect.  Another  conclusion  arrived  at  was 
that  putrid  substances  administered  subcutaneoush'  ma}-  produce 
gangrene,  phlegmonous  inflammation,  or  er^'sipelas,  according  to  the 
stage  of  putrefaction,  temperature,  culture-soil,  etc.  The  infective 
material  was  never  found  in  the  blood,  but  always  in  the  products  of 
inflammation.  It  M'as  clearly  stated  that  true  septicaemia  is  alwa3's 
preceded  by  a  stage  of  incubation,  and  that  its  contagium  is  destroyed 
by  boiling,  putrefaction,  and  germicides. 

Bergmann  and  Augerer  produced  a  condition  in  animals  resembling 
septicaemia,  by   injecting  into  the  circulation  pepsin,   pancreatin,  and 


320  PRINCIPLES   OF    SURGERY. 

trypsin.  When  death  occurred  after  intra-vascuhir  injections  of  these 
ferments,  fibrinous  deposits  were  found  in  the  heart  and  pulmonar}' 
vessels.  These  experiments  were,  therefore,  confirmatory  of  the  obser- 
vations previously  nuide  b}'  p]delberg  and  Birck,  who  had  shown  that 
the  injection  of  i)utrid  substances  into  the  circulation  materially  increased 
the  free  fibrin  ferment  in  the  circulating  blood. 

Bhimberg  concluded,  from  his  numerous  experiments  on  animals, 
that  the  symptoms  which  follow  an  injection  of  putrescent  material  into 
the  circulation  are  not  always  constant ;  that,  in  fact,  extreme  prostra- 
tion, high  temperature,  rapid  pulse  and  respiration  are  the  onl}'  constant 
sj-mptoms  found.  The  same  author  also  confirmed  the  statement  that 
the  blood  of  patients  dying  from  putrid  intoxication  contained  no 
micro-organisms.  Samuel  maintains  that  putrid  fluids,  from  the  second 
da\'  until  the  eighth  montli  of  putrefaction,  act  differentl}',  and  divides 
their  action  according  to  this  supposition  into  three  stages  :  1.  Phlogo- 
genic,  in  which  they  produce  only  inflammation.  2.  Septogenic ,  in  which 
they  produce  in  the  living  organism  putrefactive  processes.  3.  Pyogenic^ 
in  which  they  cause  only  suppuration,  having  lost  in  the  meantime  their 
other  pathogenic  qualities. 

Mikulicz  found  tliat  putrid  fluids,  according  as  they  are  free  from 
bacteria  or  contain  more  or  less  of  putrefactive  microbes,  will  produce  a 
slight  inflammation,  a  suppurative  inflammation,  or  a  progressive  phleg- 
monous inflammation.  Frankel  detected  but  few  micrococci  in  the  blood 
of  septiciemic  patients,  and  observed  that  the}'  greatly  increased  after 
death  ;  but,  after  the  lapse  of  some  further  time,  altogether  disappeared, 
thus  also  confirming  a  fact  previously  known,  that  putrefaction  destroj^ed 
septic  microbes.  These  observations  may  tend  to  harmonize  the  dis- 
crepancy of  opinion,  growing  out  of  the  diflTerent  results  obtained  by 
diff^erent  experimenters,  by  injections  of  putrid  substances,  as  some  of 
the  fluids  may  have  contained  an  abundance  of  living  micro-organisms, 
while  others  may  have  been  rendered  sterile  by  age,  owing  to  advanced 
putrefactive  changes.  Brieger  and  Maas  have  rendered  valuable  service 
in  the  chemical  isolation  of  ptomaines,  or,  as  Brieger  calls  them,  toxines, 
from  putrid  substances,  and  the  results  of  their  inoculation  experiments 
established  more  firmly  the  fact  of  putrid  intoxication  by  these  soluble 
alkaloid  substances.  The  number  of  bacteria  in  rabbits  killed  b}'  septic 
infection  is  so  great  that  death  may  ensue  from  simple  mechanical  causes, 
wliile  in  fatal  cases  of  sepsis  in  man  the  number  is  often  so  small  that  it 
seems  natural  to  suppose  that  the  micro-organisms  are  capable  of  pro- 
ducing some  poisonous  substance,  which  destroj^s  the  patient  before  they 
have  time  to  multiply'  to  the  extent  observed  in  septicaemia  in  rabbits 
and  mice. 


CLINICAL   FORMS    OF    SEPTICAEMIA.  321 

Rinue  asserts  that  the  chemical  products  of  pus-microbes  alone,  as 
well  as  sterilized  putrid  fluids,  never  produce  metastasis.  He  sterilized 
fluid  cultures  of  the  staphylococcus  p^-ogenes  aureus  after  filtration,  and 
injected  directl}'^  into  the  blood-vessels  of  rabbits  as  much  as  4  grammes 
of  this  fluid,  and  in  dogs  increased  the  dose  to  14  grammes.  Man}-  of 
the  animals  showed  slight  symptoms  of  septic  intoxication,  somnolence, 
diarrhoea,  and  collapse.  B3'  using  still  larger  doses  the  symptoms  were 
intensified  and  the  animals  died  from  well-marked  symptoms  of  septic 
intoxication.  Metastatic  abscesses  were  never  found  in  these  cases. 
The  same  author  has  recently  published  some  xevy  interesting  observa- 
tions on  the  immediate  cause  of  death  in  rabbits  inoculated  with  a  pure 
culture  of  Koch-Gaff" ky's  bacillus.  The  animals  were  inoculated  at  the 
base  of  the  ear,  and  immediatel}^  after  death  the  ptomaines  were  isolated 
from  the  tissues  b}'  Brieger's  method.  In  every  instance  he  obtained  a 
substance  called  meth^iguanidin,  which  on  chemical  analysis  was  shown 
to  consist  of  the  formula  CgH^Ng.  When  this  substance  was  injected 
into  rabbits  it  produced  s^-mptoms  of  septic  intoxication  which 
resembled,  in  eveiy  particular,  those  produced  by  the  injection  of  i)ure 
cultures  obtained  from  septicEemic  rabbits.  As  methylguanidin  could 
not  be  produced  from  the  cadavers  by  the  same  method,  Hoffa  naturally 
came  to  the  conclusion  that  it  was  a  product  of  the  bacilli,  and  that 
death  was  to  be  attributed  to  the  production  of  this  toxic  substance  in 
the  tissues  of  the  infected  animals  b^^  the  specific  action  of  the  bacilli. 
The  source  of  methj^lguanidin  in  the  body  is  kreatin,  and  the  bacteria 
must  possess  the  property  of  oxidation,  as  kreatin  is  transformed  into 
methj'lguanidin  only  bj-  oxidation.  Brieger  has  isolated  from  human 
corpses  a  different  set  of  toxic  alkaloids,  one  of  which  he  calls  "  cadav- 
erin"  and  the  other  "  putrescin,"  which  are  but  feeble  poisons  ;  while 
two  others,  "  madeleine  "  and  "  sepsin."  v*iiich  are  produced  later  on  in 
the  decomposition,  are  much  more  powerful  poisons,  causing  paralysis 
and  death.  From  decomposing  albuminous  substances  he  has  obtained 
many  other  well-defined  chemical  bodies,  as  well  as  some  substances  to 
which  no  names  have  3'et  been  given. 

Bourget  isolated  several  toxic  bases  from  the  viscera  of  a  woman 
who  had  died  of  puerperal  sepsis.  He  also  obtained  from  the  urine 
from  patients  suff"ering  from  the  same  disease  similar  toxic  bases,  which 
killed  frogs  and  guinea-pigs,  when  administered  bj'  injection,  showing 
that  the  toxic  substances  formed  during  life,  and  that  the}'  are  elimi- 
nated through  the  kidneys. 

The  experimental  and  clinical  researches  to  which  I  have  referred 
above  show  conclusively  that  septic  intoxication  is  caused  by  the  presence 
of  dead  tissue  in  the  body  in  a  state  of  putrefaction,  from  the  presence 


822  PRINCIPLES   OF   SURGERY. 

of  putrefactive  bacilli,  and  that  the  immediate  cause  of  the  intoxication 
is  the  absorption  of  preformed  ptomaines  from  such  a  local  focus  of 
putrefaction. 

Symptoms  and  Diagnosis. — Septic  intoxication  snflicient  in  severity 
to  give  rise  to  grave  general  disturbances  is  usually  initiated  by  a  chill, 
or  at  least  b}'  a  sensation  of  chilliness,  followed  by  a  continued  form  of 
fever,  the  temperature  rapidly  increasing  to  102°  to  104°  F.,  with  slight 
morning  remissions.  The  character  of  the  pulse  furnishes  the  most  reli- 
able information  in  regard  to  the  intensity  of  the  intoxication.  All 
ptomaines  of  putrefactive  bacteria  exert  a  depressing  influence  on  the 
heart;  hence  the  force  and  frequency  of  the  pulse  furnish  important 
diagnostic  and  prognostic  CAndences.  The  pulse  is  always  soft  and  com- 
pressible,— qualities  which  indicate  diminished  intra-vascular  pressure, 
resulting  from  an  enfeebled  vis  a  tergo.  Complete  loss  of  appetite, 
vomiting,  and  diarrhoea  are  almost  constant  symptoms  in  grave  cases. 
The  tongue  is  usually  furred,  dry,  and,  in  severe  cases,  presents  the 
"  dried-beef "  appearance.  The  urine  is  scanty  and  heavily  loaded  with 
urates.  Headache  is  often  complained  of  in  the  beginning  of  the  attack. 
Delirium,  restlessness,  insomnia,  are  symptoms  which  denote  approach- 
ing danger.  Subsultus,  dilatation  of  pupils,  clammy  perspiration,  livid 
appearance  of  visible  mucous  membranes,  low-muttering  delirium,  invol- 
untary discharges,  coldness  of  the  extremities,  fluttering,  and  feeble  pulse 
precede  death  from  septic  intoxication.  One  of  the  most  important 
elements  in  the  diagnosis  is  the  detection  of  a  local  focus  of  putrefaction. 
As  the  putrefaction  alwa^^s  occurs  in  parts  of  the  bod}'  exposed  to  the 
atmospheric  air,  its  existence  can  readily  be  ascertained  by  the  sense  of 
smell.  The  intensity  of  the  foetor  of  the  gases  produced  by  the  putrefac- 
tive bacteria  varies  greatly,  but  the  smell  is  always  suggestive  of  decom- 
posing meat  or  kitchen  refuse.  The  impression  is  quite  prevalent,  not 
only  among  the  laity,  but  also  in  the  profession,  that  the  local  lesions 
which  cause  septicaemia  always  emit  a  fetid  odor.  This  is  a  grave  mis- 
take. Foetor  is  associatad  ivith  putrefaction ,  and  as  such  is  suggestive  of 
saprsemia,  and  not  true  progressive  sepsis.  The  latter  may  be  combined 
with  saprsemia,  but  when  it  occurs  independently  of  this  no  bad  smell 
can  be  detected,  and  yet  it  is  the  most  fatal  form  of  sepsis.  In  reference 
to  the  differential  diagnosis  between  saproemia,  fermentation  fever,  and 
septic  infection,  it  must  be  remembered  that  septic  intoxication  can  onl}^ 
occur  from  putrefaction,  and  therefore  three  conditions  must  invariably 
be  present  in  the  etiology  of  this  form  of  sepsis:  1.  Dead  tissue.  2. 
Infection  of  this  dead  tissue  with  putrefactive  bncteria.  3.  A  sufficient 
length  of  time  must  have  elai)sed  since  the  injury  or  operation  for  the 
putrefactive  bacteria  to  produce  a  toxic  quantity  of  ptomaines  to  cause 


CLINICAL    FORMS    OF    SEPTICEMIA.  323 

symptoms  of  intoxication.  The  dead  tissue  ma}^  be  a  blood-clot  in  a 
wound,  around  the  fragments  of  a  compound  fracture,  or  in  the  interior 
of  the  uterus  ;  it  may  be  tissue  devitalized  b^-  a  trauma,  heat  or  cold, 
the  action  of  chemical  substances,  or  the  action  of  bacteria  other  than 
putrefactive  ;  or  it  may  be  detached,  retained  fragments  of  placental 
tissue.  That  such  dead  tissue  has  become  the  seat  of  infection  with 
putrefactive  bacteria  can  be  ascertained  by  the  presence  of  foetor  and 
bubbles  of  gas.  At  the  temperature  of  the  bod}-  putrefaction  progresses 
verj'  rapidly  ;  but  a  differential  diagnosis  can  generall}'  be  made  without 
much  difficult}',  between  saprsemia  and  fermentation  fever,  b}-  the  time 
which  has  elapsed  between  the  injur}'  or  operation  and  the  manifesta- 
tion of  the  first  symptoms  of  septic  intoxication.  Fermentation  fever 
appears  within  a  few  hours,  certainly  always  before  the  end  of  the  first 
da}',  while  septic  intoxication  from  putrefaction  seldom  begins  before 
the  expiration  of  twenty-four  hours.  If  septic  infection  begin  during 
this  time  it  is  not  attended  by  any  evidences  of  putrefaction. 

Prognosis. — Uncomplicated  saprsemia  proves  fatal  by  the  absorption 
of  a  deadly  dose  of  ptomaines  from  a  local  depot  of  putrefaction,  and 
the  prognosis  will  therefore  depend  upon  the  stage  of  intoxication  and 
the  feasibility  of  the  removal  of  the  infected  dead  tissue  by  sui'gical 
treatment.  If  an  efficient,  radical  treatment  can  be  instituted  at  a  time 
before  a  fatal  dose  of  toxic  substances  has  reached  the  general  circula- 
tion, the  prognosis  is  favorable.  A  decomposing  blood-clot  or  detached 
fragment  of  a  placenta  can  be  readily  removed  and  the  field  of  operation 
sterilized.  The  prognosis  in  saprsmia  complicating  progressive  gan- 
grene is  always  grave, as  the  dead  tissue  is  increased  by  other  microbes; 
hence  the  conditions  created  by  both  kinds  of  microbes  are  of  a  pro- 
gressive character. 

Treatment. — The  prophylactic  treatment  of  sapramia  consists  in  the 
removal  of  dead  tissue,  prevention  of  subsequent  extravasation  and  ac- 
cumulation of  blood  by  cai-eful  hsemostasis, — if  necessary,  by  drainage, 
— and  finally  sterilization,  by  antiseptic  measures,  of  dead  tissue  that 
cannot  be  removed.  lodoformization  of  dead  tissue  is  an  excellent 
means  of  preservation.  In  the  extra-peritoneal  treatment  of  the  stump 
after  supra-vaginal  extirpation  of  the  uterus,  the  same  object  is  accom- 
plished by  toucliing  the  raw  surface  with  a  solution  of  perchloride  or 
persulphate  of  iron  or  pure  carbolic  acid.  Wounds  in  which  dead  tissue 
is  unavoidably  retained  should  always  be  treated  by  drainage.  After 
symptoms  of  septic  intoxication  have  developed  early,  radical  treatment 
must  be  pursued.  This  treatment  comprises  the  removal  or  sterilization 
of  the  dead  tissue.  A  decomposing  blood-clot  .is  to  be  removed  and  the 
parts  are  thoroughly  irrigated  with  a  solution  of  corrosive  sublimate,  and 


324  PRINCIPLES   OF    SURGERY. 

re-iic'ciimuliitioa  prevented  by  efficient  drainage.  In  cases  of  gangrene 
complicated  by  putrid  intoxication,  where  it  is  impossible  to  remove  the 
infected  tissues  b^^  mechanical  measures,  and  complete  disinfection  with- 
out such  a  procedure  cannot  be  effected,  the  best  results  are  obtained  by 
permanent  irrigation  with  a  saturated  solution  of  acetate  of  aluminum. 
Under  this  treatment  the  soluble  toxic  substances  are  washed  away  as 
fast  as  the}'^  are  formed,  and  sterilization  of  the  soil  for  the  putrefactive 
bacteria  is  gradually  accomplished  by  the  saturation  of  the  dead  tissue 
with  this  safe  and  efficient  autiseptic  solution.  If  a  suppurating  cavity 
is  the  seat  of  putrefactive  changes,  it  becomes  necessary  to  remove  the 
nutrient  medium  for  putrefactive  bacteria  by  first  washing  out  the  cavity 
with  a  strong  antiseptic  solution,  to  be  followed  by  the  mechanical  re- 
moval of  dead  tissue,  shreds  of  connective  tissue,  dead  granulations,  etc., 
by  means  of  a  sharp  spoon  or  dull  curette,  and  subsequently  b}'  another 
antiseptic  irrigation.  The  surgical  treatment  of  saprtemia  will  soon 
decide  the  fate  of  the  patient.  If  a  fatal  dose  of  ptomaines  has  reached 
the  general  circulation  before  an  effort  is  made  to  procure  sterilization 
of  a  local  depot  of  putrefaction  the  local  treatment  will,  of  course,  prove 
unsuccessful  in  preventing  a  fatal  result,  and  the  disease  will  continue 
its  relentless  course  uninfluenced  by  the  treatment.  If,  however,  the  in- 
toxication has  not  progressed  to  this  extent,  efficient  local  treatment  is 
followed  by  the  most  brilliant  results.  Within  a  few  hours  after  the 
sterilization  of  the  local  focus  of  putrefaction  the  temperature  falls  to 
normal,  the  pulse  becomes  slower  and  fuller.  If  the  tongue  has  been  drj'- 
it  soon  becomes  moist ;  if  the  patient  has  been  delirious  consciousness 
returns,  and  the  patient  is  convalescent  in  a  few  days.  The  results  of 
the  antiseptic  local  treatment  in  these  cases  are  the  strong  contrast  with 
the  useless  and  often  dangerous  internal  administration  of  antipyretics. 
The  treatment  directed  toward  the  disinfection  of  the  local  focus  of 
putrefaction  removes  the  cause  of  the  intoxication,  while  the  antipyretics 
may  effect  a  temporary  reduction  of  the  temperature,  but  at  the  same 
timCjb}^  diminishing  the  contractile  power  of  the  heart,  onl}^  add  to  the 
danger  by  diminishing  the  resistance  to  the  action  of  a  depressing  poison. 
The  use  of  antip3'retics  in  the  treatment  of  saprtemia  is  strongly  contra- 
indicated.  All  debilitating  treatment  must  be  carefully  avoided  as  being 
unscientific  and  as  adding  to  the  existing  dangers.  The  best  results  are 
obtained  by  such  local  treatment  by  which  the  further  production  of 
ptomaines  is  prevented,  consequentl\'  hy  measures  ivhich  meet  the  etio- 
logical indications.  The  debilitating  effects  of  the  ptomaines  on  the 
heart  are  met  by  the  timely  and  judicious  administration  of  stimulants. 
In  urgent  cases  such  diffusible  stimulants  as  sulphuric  ether,  camphor, 
and  musk  can  be  administered  with  advantage  subcutaneouslj^,  in  order 


CLINICAL    FORMS    OF    SEPTICEMIA.  325 

to  gain  time  for  the  action  of  remedies  which  will  have  a  more  permanent 
effect  on  the  heart.  Digitalis,  strophanthus,  strychnia,  and  atropia  in 
small  doses  are  excellent  cardiac  tonics  and  stimulants,  and  are  indicated 
in  cases  where  the  pulse  is  veiy  rapid  and  soft,  denoting  a  feeble 
peripheral  circulation  from  a  weakened  heart.  Where  life  is  threatened 
from  sjncope  the  patient  is  not  allowed  to  assume  a  sitting  postion,  for 
fear  that  the  increased  intra-cardiac  pressure  might  result  in  sudden 
death  from  heart-failure. 

Alcoholic  stimulants  are  to  be  given  in  doses  sufficiently  large  to 
improve  the  character  of  the  pulse,  and  at  sufficiently-  short  intervals  to 
maintain  this  effect  without  interruption.  Brandy  or  whisk}-,  in  doses 
of  an  ounce  ever}'  two  hours,  diluted  with  water,  are  most  to  be  relied 
upon,  but  champagne,  Greek  sherr}',  or  Reich's  Tokayer  are  excellem 
substitutes.  If  the  stomach  is  irritable  or  the  S3'mptoms  are  less  urgent, 
concentrated  liquid  food,  like  beef-tea,  milk,  and  eggnogg,  must  be  giA-en 
at  regular  intervals  to  assist  the  action  of  stimulants  in  sustaining  the 
heart's  action  until  sufficient  time  has  been  gained  for  the  elimination  of 
the  ptomaines. 

(c)  Progressive  Septicaemia. — This  is  the  septic  infection  of  modern 
authors,  and  differs  from  septic  intoxication  in  that  it  is  caused  not  by 
putrefactive  bacteria,  but  by  microbes  which  enter  the  circulation  from 
some  local  septic  focus,  and  which  retain  their  capacity  of  reproduction 
in  the  blood.  It  is  called  progressive  sepsis,  because,  only  too  often, 
it  is  not  followed  by  any  abatement  of  the  s^^mptoms,  as  the  essential 
cause  has  passed  beyond  the  reach  of  any  local  treatment,  and  goes  on 
increasing  in  the  blood  until  it  destroj's  the  patient.  The  intoxication 
in  this  form  of  sepsis  is  not  only  caused  hy  p>tomaines  ivhich  are  produced 
at  the  primary  seat  of  infection,  but  ptomaines  are  also  produced  in  the 
blood  by  the  microbes  which  it  contains. 

True  pi'ogressive  sepsis  is  caused  by  the  introduction  of  septic 
micro-organisms  into  the  tissues,  where  the}^  multipl}^  and,  later,  reach 
the  blood,  where  mural  implantation  and  capillary  thrombosis  take 
place,  which  directl}'  interfere  with  the  proper  nutrition  and  function 
of  important  organs,  and  where  the  septic  intoxication  is  caused  b}'^  the 
formation  of  ptomaines,  both  in  the  blood  and  living  tissues.  For  this 
form  of  sepsis  Neelsen  has  suggested  the  name  of  "  acute  mycosis  of 
the  blood,"  to  distinguish  it  from  putrid  intoxication,  which  we  have 
just  described,  and  which  Neelsen  calls  "  toxic  m3'Cosis  of  the  blood," 
in  which  few  or  no  microbes  are  found  in  the  blood,  and  in  which  death 
is  due  exclusively  to  the  absorption  of  preformed  toxic  substances  from 
a  putrefying  depot. 

Causes. — Klebs  discovered  and  described  a  microbe,  the  mikrosporon 


326  PRINCIPLES   OF    SURGERY. 

sepiiciim,  which  he  believed  was  the  specific  cause  of  septic  processes, 
but  recent  researches  seem  to  prove  that  the  pus-microbes  are  the  most 
frequent  cause  of  progressive  sepsis.  Tlie  pus-microbes  either  reach  the 
circulation  directly  by  permeating  the  vessel-wall,  or  they  enter  by  a 
more  indirect  route,  through  the  lymphatic  channels.  The  latter  mode 
of  infection  gives  rise  to  the  most  acute  and  fatal  form  of  sepsis.  In 
many  cases  of  septic  infection  the  presence  of  l^nnphangitis  can  be 
demonstrated  during  life,  and  bj^  examination  after  death.  A  few  years 
ago  Bergmann  advanced  the  theory  that  in  septicaemia  micro-organisms 
enter  the  colorless  blood-corpuscles,  and  by  multiplication  within  them 
cause  their  dissolution,  a  process  during  which  the  fibrin-generators  are 
elaborated, — an  occurrence  ending  in  intra-vascular  coagulation  and 
capillar}'  embolism.  In  Koch's  septicaemia  in  mice  such  a  chain  of 
pathological  conditions  can  be  readil}^  demonstrated,  but  in  many  cases 
of  fatal  sepsis  in  man  the  microbes  found  in  the  blood  are  few,  no  de- 
struction of  leucocytes  can  be  shown  to  have  occurred,  and  extravasations 
and  capilhuy  embolism  are  absent;  hence  death  cannot  be  attributed  to 
fibrin  intoxication.  In  such  instances  we  can  only  assume  the  j^f'ssence 
of  a  soluble  ptomaine  which  is  diffused  throughout  the  entire  body  and 
destroys  life  by  its  toxic  j^roperties.  The  formation  of  pus  at  the  primary 
seat  of  infection  is  not  necessary  in  the  causation  of  septicaemia  by  pus- 
microbes.  Septic  infection  is  as  liable  to  take  place  from  wounds  that 
do  not  suppurate  as  from  suppurating  wounds,  "Why  a  wound  infected 
with  pus-microbes  should  give  rise  to  progressive  sepsis  in  one  individual, 
and  suppuration  or  suppuration  and  pyaemia  in  another,  does  not  admit 
of  a  satisfactory  explanation  at  the  present  time. 

Rinne  has  shown  that  diminution  of  the  absorptive  capacit}^  of  the 
tissues  at  the  seat  of  infection  plays  an  important  part  in  the  develop- 
ment of  septic  processes.  If  the  pus-microbes  are  rapidly  absorbed, 
destroyed  in  the  blood,  or  removed  by  elimination,  septic  inflammation 
is  prevented.  If,  on  the  other  hand,  the  local  conditions  are  such  that 
the  microbes  remain  in  the  tissues,  and  b}-  their  rapid  multiplication 
produce  a  large  amount  of  soluble  toxines,  which,  when  they  reach  the 
blood,  not  only  produce  intoxication,  but  prepare  the  blood  and  tissues 
for  the  localization  and  reproduction  of  the  microbes  at  points  distant 
from  the  primary  seat  of  the  infection,  the  pathogenic  eflect  of  the 
microbes  on  the  tissues  at  the  primary  seat  of  infection  diminishes  their 
power  of  resistance,  and  the  microbes  either  enter  the  blood-vessels 
directly  or  through  the  l3aiiphatics.  Experimental!}'  it  has  been  shown 
that  if  a  large  qunntity  of  pus-microbes  is  introduced  into  the  peritoneal 
cavity,  or  directly  into  the  circulation,  death  results  from  sepsis  before 
a  sufficient  length  of  time  has  elapsed  for  the  pus-microbes  to  produce 


CLINICAL   FORMS    OF    SEPTICEMIA.  327 

the  histological  changes  which  are  necessary  for  the  production  of  pus. 
These  experiments  are  strongly  suggestive  of  the  fact  that,  in  man,  infec- 
tion ivith  pus-microbes  causes  jyj'ogressive  sejisis,  if  a  large  quantity  of 
pus-microbes  is  introduced  into  tissues  debilitated  by  a  trauma,  antecedent 
pathological  conditions,  or  the  action  of  preformed  ptomaines.  Under 
such  circumstances  the  i)us-microl)es  are  reproduced  "with  great  rapidity 
at  the  primar}'  focus  of  infection,  enter  the  circulation  before  suppu- 
ration has  had  time  to  develop,  and  produce  a  complexus  of  symptoms 
and  a  series  of  pathological  changes  characteristic  of  progressive 
sepsis. 

Symptoms  and  Diagnosis. — The  most  typical  clinical  picture  of 
progressive  sepsis  is  produced  in  cases  of  septic  peritonitis,  dissection 
wounds,  puerperal  septicaemia,  and  acute  multiple  osteomyelitis.  In  septic 
peritonitis,  after  laparotomy  or  penetrating  wounds  of  the  abdomen,  the 
septic  inflammation,  as  a  rule,  develops  within  the  first  forty-eight  hours, 
and  with  it  the  characteristic  symptoms  of  septicaemia  appear.  In 
puerperal  sepsis  and  the  gravest  form  of  acute  suppurative  osteomyelitis, 
the  septic  symptoms  often  overshadow  the  primary  disease  to  such  an 
extent  that  this  is  entireh'  overlooked.  Dissection  wounds  often  prove 
fatal  from  septic  infection,  which  spreads  from  the  wound  along  the 
course  of  the  lymphatic  vessels,  and  finally  becomes  general  through  the 
medium  of  the  circulation.  Septic  infection  from  an  accidental  or 
operative  wound  can  take  place  within  twentj^-four  hours,  and  seldom 
occurs  later  than  the  third  or  fourth  day,  unless  the  infection  has  taken 
place  after  tlie  first  dressing.  Like  all  other  acute  infectious  processes, 
septicsemia  is  ushered  in  by  a  more  or  less  pronounced  chill,  or  at  least 
a  subjective  sensation  of  chilliness,  which  may  be  repeated  during  the 
first  twent3--four  hours.  The  chill  is  never  so  pronounced  as  in  p3-£emia, 
and  does  not  return  with  the  same  regularity  and  intensitj-  as  in  that 
affection.  The  chill  announces  the  termination  of  the  period  of  incuba- 
tion, and  is  promptl}'  followed  by  s3'mptoms  of  reaction  which,  in  their 
severity,  are  proportionate  to  the  intensity  and  gravity  of  the  attack. 
One  of  the  most  prominent  features  of  the  disease  is  a  profound  pros- 
tration, which  may  be  well  marked  a  few  hours  after  the  beginning  of 
the  attack.  If  septicaemia  follow  an  operation,  or  a  severe  accident,  it 
is  sometimes  almost  impossible  to  decide  whether  the  pronounced  loss 
of  strength  should  be  attributed  to  shock,  the  use  of  an  anaesthetic,  or 
the  beginning  of  an  attack  of  septicaemia.  One  of  tlie  most  delusive 
s^'mptoms  is  the  utter  indiiference  of  the  patient,  not  only  as  to  his  own 
grave  condition,  but  to  all  of  his  surroundings.  This  apathy  is  a  char- 
acteristic symptom  of  profound  septic  intoxication.  The  patient  com- 
plains of  no  pain,  assures  the  physician  and  friends  that  he  is  feeling 


328  PRINCIPLES    OF    SURGERY. 

well,  shows  jibsolutel}'  no  anxiety  concerning  his  own  fate,  and  does 
not  comprehend  the  anxiety  of  those  aronnd  him.  Drowsiness,  border- 
ing almost  on  stupor,  is  frequently  observed.  The  face  presents  a  pale 
or  ashy-gray  color,  and  in  advanced  cases  it  presents  a  3'ellowish,  icteric 
tint,  but  the  sclerotica  always  retains  its  white  color.  In  the  beginning 
of  the  attack  the  pulse  ranges  between  80  and  90  degrees,  but  becomes 
rapid,  small,  and  compressible  as  the  intoxication  and  capillary  obstruc- 
tion progress.  The  character  of  the  pulse  is  of  great  diagnostic  and 
prognostic  importance.  If  the  pulse  within  a  short  time  reach  a  fre- 
quency of  140,  and  imparts  the  sensation  as  though  the  artery  were  only 
half  filled  with  blood,  it  is  a  s3^mptom  which  forebodes  immediate  danger. 
The  temperature  is  variable.  A  subnormal  temperature,  with  a  rapid, 
feeble  pulse,  indicates  a  grave  and  probably  fatal  form  of  sepsis.  If  the 
temperature  is  at  first  only  slightly  increased,  but  gradually  rises  to  103° 
or  104°  F.,  it  denotes  progressive  sepsis.  A  high  temperature  and  a 
firm  pulse,  not  exceeding  120  beats  to  the  minute,  are  indications  of  less 
serious  import  than  a  low  temperature  with  a  rapid,  feeble  pulse.  The 
eyes  are  sunken,  often  suffused  with  an  abundant  secretion  from  the 
conjunctiva.  The  features  present  a  stolid  appeai'ance,  without  any 
expression  of  intelligence.  Capillary  oozing  at  the  primary  seat  of 
infection  is  a  common  occurrence,  and  capillar}^  haemorrhage  underneath 
the  skin  and  visible  mucous  membranes  is  frequently  observed.  Vom- 
iting and  diarrhoea  are  often  present  from  the  beginning,  and  in  rapidly 
fatal  cases  remain  as  persistent  symptoms,  in  spite  of  measures  that  may 
be  employed  to  subdue  them.  The  discharges  from  the  bowels  are  often 
stained  with  blood.  The  urine,  as  a  rule,  is  scanty  and  loaded  with 
urates. 

Billroth  places  great  importance  upon  the  appearance  of  the  tongue. 
The  tongue  is  always  coated  ;  in  grave  cases  it  is  pointed  at  the  tip,  its 
margins  are  red,  while  the  dorsal  surface  is  dry  and  covered  with  a  dry, 
often  almost  black,  crust.  Return  of  moisture  is  always  a  favorable  omen. 
Great  thirst  and  complete  loss  of  appetite  are  always  present.  Delirium 
is  a  frequent,  but  not  a  constant,  symptom.  If  the  case  progress  to  a 
fatal  termination,  the  pulse  becomes  more  and  more  frequent,  respira- 
tions become  shallow  and  labored,  the  face  presents  a  cj'anotic  hue,  the 
surface  is  bathed  with  a  clammy  perspiration,  the  extremities  become 
cold,  and  death  finally  is  caused  from  heart-failure.  In  the  differential 
diagnosis  it  is  important  to  remember  fermentation  fever,  septic  intoxi- 
cation, typhoid  fever,  internal  sepsis,  and  acute  multiple  suppurntive 
osteomyelitis.  Progressive  septicaemia  always  has  a  stage  of  incubation  ; 
that  is,  a  certain  length  of  time  intervenes  between  the  time  infection 
occurred  and  the  appearance  of  the  disease.     This  period  of  incubation 


CLINICAL   FORMS   OF    SEPTICEMIA.  329 

may  terminate  at  the  end  of  a  few  hours  and  it  may  be  prolonged  to 
four  days,  according  to  the  number  of  pus-microbes  introduced  and  the 
anatomical  structure  and  pli3^siological  properties  of  the  tissues  primarily 
infected.  Fermentation  fever  follows  an  injury  or  operation  within  a  few 
hours,  and  never  occurs  after  the  expiration  of  twenty-four  hours.  In 
fermentation  fever  the  maximum  symptoms  appear  at  once,  and  the  force 
of  the  pulse  and  strength  of  the  patient  remain  unimpaired.  Fermenta- 
tion fever  seldom  lasts  for  more  than  one  or  two  days,  while  in  progres- 
sive sepsis  the  s3'mptoms  become  aggravated  as  the  infection  increases. 
In  putrid  intoxication  the  maximum  symptoms  are  pi'oduced  b}'  the  in- 
troduction into  the  blood  of  preformed  soluble  toxic  substances  from  a 
depot  of  putrefaction.  Evidences  of  putrefaction  in  an}'  part  of  the 
bod}^  would  speak  in  favor  of  septic  intoxication,  while,  if  septic  infec- 
tion exist  at  the  same  time,  it  must  be  regarded  not  in  the  light  of  a 
cause,  but  as  a  complication.  Typhoid  fever  is  preceded  by  a  well- 
marked  prodromal  stage  which  is  absent  in  septic  infection.  The  erup- 
tion in  t^'phoid  fever  is  characteristic,  while  the  eruption  which  is 
sometimes  seen  in  progressive  sepsis  closely  resembles  the  rash  of  scar- 
latina, and  is  caused  by  the  presence  of  pus-microbes  in  the  superficial 
lymphatic  vessels.  Internal  sepsis  is  usually  preceded  by  a  septic  phar- 
yngitis, and  frequently  attended  by  ulcerative  endocarditis.  Acute  mul- 
tiple osteomj-elitis,  the  cause  of  fatal  septic  infection,  can  be  recognized 
b}'  searching  for  points  of  tenderness  in  the  localities  attacked  most  fre- 
quently b}'  this  disease.  The  final  diagnosis  of  septic  infection  must  be 
based  upon  the  existence  of  an  infection-atrium,  through  which  pus- 
microbes  have  entered  the  tissues,  and  from  which  the}^  have  reached  the 
general  circulation. 

Prognosis. — The  prognosis  of  progressive  septicemia  is  always 
grave.  In  cases  where  pus-microbes  exist  in  large  numbers  at  the  pri- 
mary seat  of  infection,  and  reach  the  general  circuhition  with  great 
rapidity^,  and  meet  with  conditions  favorable  for  their  reproduction, 
death  is  inevitable  in  spite  of  the  most  energetic  local  and  general  treat- 
ment. The  prognosis  is  more  favorable  if  infection  has  taken  place  from 
a  localit}'  amenable  to  thorough  local  disinfection,  if  this  is  practiced 
upon  the  first  appearance  of  S3'mptoms,  as  this  treatment  prevents  fur- 
ther ingress  of  pus-microbes  into  the  circulation.  The  existence  of  mul- 
tiple points  of  metastatic  inflammation  renders  a  recover}-  improbable. 
Delirium,  rapid  and  feeble  pulse,  subnormal  temperature,  dry  tongue, 
persistent  vomiting  and  diarrhoea  are  all  unfavorable  symptoms  from  a 
prognostic  stand-point.  Capillary  haemorrhages  distant  from  the  primary 
infection-atrium  are  infallible  indications  of  progressive  sepsis,  and 
their  existence  warrants  a  most  unfavorable  prognosis.      Progressive 


330  PRINCIPLES   OF   SURGERY. 

sepsis  ma}'  cause  death  in  twelve  hours,  and  in  fatal  cases  life  is  seldom 
prolonged  for  more  than  one  week. 

Pathology  and  Morbid  Anatomy. — In  rapidly-fatal  cases  of  progres- 
sive septic  infection,  tlie  absence  of  gross  macroscopical  pathological 
changes  is  a  characteristic  feature  of  this  disease.  In  such  instances 
even  the  most  careful  search  for  tangible  lesions  will  result  negatively. 
Cloudy  swelling  of  the  parenchyma  of  internal  organs  indicates  the 
existence  of  coagulation  necrosis,  caused  by  the  action  of  the  ptomaines 
of  the  pus-microbes.  Pus-microbes  have  been  frequently  found  in 
septic  blood.  IliTeniorrhagic  extravasations  into  organs,  and  more  par- 
ticularly underneath  serous  and  mucous  membranes  and  the  skin,  are 
frequently  present.  The  blood  presents  almost  a  black  color,  and  shows 
little  or  no  tendency  to  coagulate.  The  lymphatics  interposed  between 
the  primary  seat  of  infection  and  the  blood-vessels  are  frequently  found 
in  a  state  of  septic  inflammation.  The  wound  through  which  infection 
has  taken  place  may  present  but  slight  or  no  gross  anatomical  changes. 
The  spleen  is  enlarged  and  the  pulpa  softened  to  the  consistency^  of  a 
blood-clot.  Thrombosis  and  embolism  are  absent.  Under  the  micro- 
scope the  capillary  vessels  everywhere  present  all  the  evidences  of  a 
septic  inflammation.  The  soluble  ptomaines  in  the  blood  produce  coagu- 
lation necrosis  of  the  intima,  which  determines  mural  implantation  of 
the  pus-microbes  and  the  colorless  corpuscles  and  results  in  capillary 
hy[)er8emia  and  congestion.  In  some  places  alteration  of  the  capillary 
wall  has  taken  place  to  such  an  extent  as  to  give  rise  to  rhexis.  The 
most  important  microscopical  changes  in  the  tissues  and  organs,  in 
patients  who  have  died  of  sepsis,  are  the  pathological  conditions  within 
and  in  the  immediate  vicinity  of  capillar}'  vessels  that  indicate  the  exist- 
ence of  multiple  foci  of  metastatic  inflammation,  which  characterize 
clinicall}'  and  putliologically  progressive  sepsis.  If  life  is  prolonged  for 
a  suflicient  length  of  time,  these  foci  become  the  centre  of  a  suppura- 
tive inflammation.  Slight  eff"usions  into  tlie  large  serous  cavities  are 
frequentl}^  found. 

Treatment. — The  antiseptic  measures  which  have  been  described  in 
the  treatment  of  wounds  are  the  best  and  only  known  means  of  effective 
prophylaxis  against  septic  infection.  Any  method  or  methods  of  treat- 
ment which  can  be  relied  upon  in  the  prevention  of  suppuration  will 
be  found  efficient  in  preventing  septic  infection.  As  retention  of 
wound-secretion  is  one  of  the  important  etiological  conditions  in  the 
causation  of  septic  infection  in  Avounds  that  are  not  completel}'  aseptic, 
drainage  should  be  employed  in  all  cases  where  an  accuuiuhition  of  the 
primary  wound-secretion  is  to  be  feared.  As  septic  infection  is  just  as 
liable  to  occur  through  a  small  as  a  large  wound,  the  most  insignificant 


CLINICAL    FORMS   OF    SEPTICEMIA.  331 

injuiy  should  be  treated  upon  the  strictest  aud  most  pedantic  antiseptic 
precautions.  If,  in  spite  of  the  greatest  care,  s3'mptoms  of  septic 
infection  appear  after  an  injury  or  operation,  no  time  should  be  lost  by 
the  useless  administration  of  antipj'retics,  in  the  vain  hope  that  by 
reducing  the  temperature  the  condition  of  the  patient  will  be  improved, 
but  the  first  and  essential  object  of  treatment  should  be  to  remove  the 
cause  of  the  fever  by  resorting  to  secondary  disinfection.  All  sutures 
must  be  removed  and  ever}-  portion  of  the  wound  rendered  accessible  to 
local  treatment.  Extravasated  blood  and  necrosed  shreds  of  tissue 
must  be  removed,  wlien  the  wound  is  to  be  irrigated  with  a  1-to-lOOO  solu- 
tion of  corrosive  sublimate,  after  which  it  is  dried  and  the  whole  surface 
brushed  with  a  10-per-cent.  solution  of  chloride  of  zinc.  After  another 
irrigation  and  after  drying  the  surface  again,  a  thin  film  of  iodoform  is 
applied,  and  then  the  wound  is  tamponed  with  iodoform  gauze  and 
dressed  antiseptically.  Such  a  wound  should  never  be  re-sutured  until 
tlie  local  and  general  s3'mptoms  indicate  that  it  has  been  rendered 
completeh'  aseptic.  If  this  secondary  disinfection  prove  unsuccessful, 
recourse  should  be  had  to  permanent  irrigation  with  a  saturated  solution 
of  acetate  of  aluminum.  Secondary  disinfection  of  the  peritoneal  cavity, 
in  cases  of  septic  peritonitis  after  laparotom}^,  has  so  far  not  proved 
ver3"  satisfactory^  but  as  it  is  the  onl}^  recourse  in  dealing  with  such 
desperate  cases,  that  without  it  would  surely  run  a  fatal  course  in  a 
short  time,  it  should  never  be  neglected.  A  number  of  the  sutures 
near  the  lower  angle  of  the  wound  are  removed  Avitli  blunt  instruments, 
the  margins  of  the  wound  are  separated,  and  the  abdominal  cavity  is 
flushed  with  warm  salicylated  water  until  the  fluid  returns  perfectly 
clear.  The  end  of  the  rubber  tube  attached  to  the  irrigator  must  be 
inserted  in  such  a  manner  that  the  stream  will  reach  the  most  depend- 
ent portions  of  the  abdominal  cavity  ;  hence  it  is  inserted  into  the  deep- 
est portion  of  the  pelvis,  and  when  this  portion  of  the  abdominal  cavity 
has  been  thoroughly  washed  out  the  lumbar  regions  are  dealt  with  in 
a  similar  manner.  After  the  irrigation  has  been  completed,  the  patient 
is  turned  upon  the  face,  so  as  to  permit  the  escape  of  fluid  b}-  gravita- 
tion. A  large  glass  drain  is  then  inserted  and  its  opening  closed  with 
salicylated  cotton,  after  which  the  antiseptic  di'essing  is  applied  in  such 
a  manner  that  the  end  of  the  tube  remains  accessible  to  the  removal  of 
fluid  1)3'  aspiration  as  often  as  circumstances  ma3'  require.  In  progres- 
sive sepsis,  following  in  the  course  of  progressive  gangrene  of  a  limb, 
amputation  will  become  necessar3'  if  secondar3'  disinfection  and  perma- 
nent irrigation  have  proved  of  no  avail  in  arresting  the  septic  infection. 
Tlie  general  treatment  of  septic  infection  is  the  same  as  has  been  advised 
in  cases  of  septic  intoxication. 


CHAPTER  XIII. 

Pyemia. 

Pyemia,  or  pj'ohaemia,  is  a  general  disease  caused  by  tlie  entrance 
into  the  circulation  of  pus  or  some  of  its  component  parts,  characterized 
by  recurring  chills,  an  intermittent  form  of  fever,  and  the  occurrence 
of  metastatic  abscesses.  Although  this  disease  .was  known  a  long  time 
before  Piorr}'  applied  to  it  the  name  it  still  bears,  its  intimate  relation- 
ship to  suppurative  processes  was  first  pointed  out  by  this  surgeon. 
Piorr}'  maintained  that,  as  the  name  implies,  pj^ffimia  is  caused  b}'  the 
entrance  of  pus  into  the  blood.  A^irchow,  on  the  other  hand,  contended 
that  no  pus  is  found  in  the  blood  of  pyaemic  patients,  and  that  the  sec- 
ondary or  metastatic  abscesses  are  not  true  abscesses  resulting  from  the 
accumulation  of  pus  derived  from  the  blood,  but  that  the}'  are  the  result 
of  embolic  processes,  puriform  softening,  inflammation,  and  suppuration 
around  the  blocked  vessel.  Recent  bacteriological  investigations  have 
shown  that  Piorry's  views  are  so  far  correct  in  that  pus  is  produced 
within  blood-vessels  by  the  entrance  of  pus-microbes  into  the  circula- 
tion. As  a  wound  complication  pyaemia  can  only  occur  after  suppura- 
tion has  taken  place  in  a  wound,  and,  as  a  complication  of  non-traumatic 
lesions,  it  can  only  develop  in  the  course  of  suppurative  affections.  The 
great  prevalence  of  pj-femia  in  overcrowded  and  badly-ventilated  hos- 
pitals, during  the  time  before  the  antiseptic  treatment  of  wounds  came 
into  use,  gave  rise  to  a  general  belief  that  the  disease  was  due  to  a  spe- 
cific cause,  and  ever  since  bacteriology  became  a  science  diligent  search 
has  been  made  to  discover  the  specific  microbe.  Since  the  discovery  of 
the  microbes  of  suppuration,  new  light  has  been  shed  upon  the  etiolog}^ 
and  pathology  of  this  disease.  Bacteriological  examinations  of  pysemic 
products  have  shown  that  one  or  more  kinds  of  pus-microbes  are  always 
present,  thus  establishing  the  direct  relationship  which  exists  between  a 
suppurating  process  in  some  part  of  the  body  and  the  development  of 
metastatic  or  pyoemic  abscesses.  Clinical  experience  has  only  corrobo- 
rated the  scientific  investigations  of  this  subject,  inasmuch  as  it  has 
shown  that  the  frequency  of  pyaemia  has  been  diminished  in  proportion 
to  the  lesser  frequency  of  suppurative  inflammation  under  the  antiseptic 
treatment  of  wounds  and  suppurating  lesions.  We  are  justified,  upon 
the  basis  of  well-established    facts,  in  claiming  that  pyaemia   is  uot  a 

■  (333) 


334  PRINCIPLES    OF    SURGERY. 

disease  per  se,  but  that  its  occnrrence  depends  upon  an  extension  of  a 
suppurative  process  from  the  primary  seat  of  infection,  and  suppuration 
in  distant  organs  by  the  transportation  of  emboli  infected  with  pus- 
microbes  through  the  systemic  circulation.  The  distant,  or  metastatic, 
abscesses  contain  the  same  microbes  which  are  found  in  tlie  wound- 
secretions,  or  in  the  abscess  from  which  the  general  purulent  infection 
took  place.  Experiments  have  shown  that  a  culture  of  pus-microbes 
from  a  furuncle  ma}'  produce  pyjEmia  in  animals,  and  that  the  microbes 
cultivated  from  a  pj^aemic  abscess,  when  injected  under  the  skin  of  an  ani- 
mal, may  cause  onl}^  a  localized  suppurative  inflammation  without  any 
general  symptoms. 

BACTERIOLOGICAL   AND    EXPERIMENTAL   RESEARCHES. 

While  the  direct  relationship  existing  between  suppuration  and  py- 
femia  was  well  understood  clinically  for  a  long  time,  it  was  left  for  Klebs 
to  demonstrate  for  the  first  time  the  direct  connection  of  the  p3'3emic 
processes  with  the  presence  of  specific  microbes.  In  his  researches  into 
the  nature  of  this  disease  during  the  Franco-Prussian  war  in  1870,  he 
discovered  in  the  pyoemic  products  certain  micro-organisms  which  he 
called  micrococci  of  pyaemia.  He  found  that  these  microbes  alwa3-s 
arranged  themselves  in  the  form  of  colonies  or  groups  which  he  termed 
zoogJcea.  He  found  this  microbe  invariably'  present,  notably  at  the  pri- 
mary seat  of  infection,  but  also  in  the  most  distant  organs, — wherever, 
indeed,  pathological  changes  occurred  during  the  course  of  the  disease. 
Pasteur,  in  studying  the  puerperal  form  of  pj'semia,  discovered  a  chain 
coccus  which  undoubtedly  was  identical  with  the  streptococcus  pyogenes, 
but  which  he  called  microbe  enchapelet.  Hueter  and  Yogt  found  a 
micro-organism  in  pysemic  products  which  they  include  among  the  mo- 
nads. Burdon-Sanderson  supposed  that  he  had  discovered  the  essential 
microbic  cause  of  pyaemia  in  the  shape  of  a  "  dumb-bell  shaped  germ,'''' 
which  in  all  probability  was  a  staphylococcus. 

SchuUer  examined  the  contents  of  metastatic  joint  aflTections  in  12 
cases  of  puerperal  pyaemia,  and  invariably  found  pus-microbes.  Rosen- 
bach  investigated  6  cases  of  typical  pyaemia  with  a  view  to  determine 
the  nature  of  the  microbes  present  in  the  p3^8emic  pi'oducts.  He  found 
t  lie  streptococcus  p3'ogenes  present  in  the  blood,  and  metastatic  deposits 
in  5  of  them;  in  2  of  these  cases  staph^dococci  were  also  present, 
although  fewer  in  number.  In  only  1  of  them  he  found  staphylococci 
alone,  and  this  case  recovered.  Pawlowsky  made  a  bacteriological  ex- 
amination of  the  pus  of  metastatic  abscesses  in  5  cases  of  pj'aemia.  In 
4  cases  he  found  the  staphjdococcus  pyogenes  aureus,  and  in  the  fifth 
case,  which  was  remarkable  for  the  extent  of  the  joint  complications,  he 


BACTERIOLOGICAL   AND    EXPERIMENTAL   RESEARCHES.         335 

found  the  streptococcus  pyogenes.  He  believes  that  the  staphj^ococcus 
P3'ogenes  aureus  is  the  usual  cause  of  pyaemia,  and  especially  of  that 
form  characterized  by  multiple  abscesses  in  the  internal  organs.  Large 
cultures  of  this  coccus  suspended  in  water  and  injected  subcutaneousl}- 
in  rabbits  caused  death,  and  at  the  necropsy  multiple  abscesses  were 
found.  He  maintains  that  pj-amia  in  man  occurs  when  disturbances  in 
the  circulation  are  present,  so  that  floating  cocci  find  favorable  points  for 
localization  within  the  blood-vessels.  He  created  such  disturbances 
artificially  in  animals  by  making  intra-venous  injections  of  cinnabar, 
with  the  result  that  the  glandular  material  determined  localization  of  the 
microbes  which  were  introduced  into  the  circulation. 

Besser  examined  bacteriologicallj'  blood,  pus,  and  parenchymatous 
fluid  from  organs  in  23  cases  of  pyaemia.  In  8  cases  the  staphylococci 
albi  and  aurei  were  found  ;  in  14,  streptococci ;  and  in  I,  streptococci  and 
staphylococci  simultaneouslj'.  The  microbes  were  discovei'ed  during  the 
patient's  life  in  pus  in  ever}'  one  of  20  cases  examiaed  ;  in  blood,  in  II 
of  12;  and  in  parenchymatous  serum,  in  1.  After  death,  in  pus,  in  17 
of  17  ;  in  blood,  4  of  9 ;  and  in  organs,  9  of  14.  Besser's  predecessors 
described  23  additional  cases  of  p^'femia,  in  14  of  which  staphylococci 
Tvere  found  ;  in  7,  streptococci.  Total,  46  cases  :  in  22,  staphylococci ;  in 
21,  streptococci ;  in  3.  both.  Besser  was  unable  to  detect  the  slightest 
morphological  or  pathogenic  difference  between  the  microbes  of  suppu- 
ration and  those  of  P3'ffimia. 

Okinschitz  made  the  relationship  which  exists  between  tlie  pus- 
microbes  and  p^ysemia  the  subject  of  bacteriological  investigation.  He 
found  that  pysemic  blood  invariabl}'  contained  either  the  streptococcus 
pyogenes  or  the  staphylococcus  pyogenes  aureus,  demonstrated  b}^ 
cultivation  and  ordinarj^  microscopical  examination.  As  the  hseraic 
microbes  seldom  showanj^  signs  of  fission,  as  compared  with  the  bacteria 
at  the  primar}'  focus,  it  is  reasonable  to  infer  that  reproduction  takes 
place  mainl}'  in  the  pus,  and  not  in  the  blood ;  hence  the  great  impor- 
tance of  thorough  disinfection  and  destruction  of  primary  foci.  The 
number  of  microbes  in  the  circulating  blood  bears  a  direct  relation  to 
the  gravity  of  the  disease.  If  they  are  abundant,  even  in  the  absence 
of  metastases  in  internal  organs,  the  prognosis  is  grave,  and  if  scant}', 
even  if  metastatic  foci  are  present,  the  prospects  of  a  favorable  termi- 
nation are  better. 

Pyaemia  in  Rabbits. — Koch  produced  pyaemia  artificial!}'  in  rabbits 
by  injecting  putrid  fiuids.  A  piece  of  a  mouse's  skin,  about  a  square 
centimetre  in  size,  was  macerated  for  two  days  in  30  grammes  of  dis- 
tilled water,  and  a  syringeful  of  this  fluid  was  injected  subcutaneously 
into  the  back  of  a  rabbit.     Two  days   the  animal  remained  apparently 


336 


PRINCIPLES   OF    SURGERY. 


A— - 


iu 


well,  then  it  began  to  eat  less,  became  gradually  weaker,  and  died  one 
hundred  and  five  hours  after  the  injection.  An  extensive  subcutaneous 
abscess  was  found  at  the  seat  of  injection.  In  the  abdominal  wall  the 
yellowish  infiltration  extended  in  parts  through  the  muscles  and  even  to 
the  peritoneum.  The  peritoneal  surface  presented  evidences  of  inflam- 
mation. The  intestines  were  adherent,  and  the  peritoneal  cavity  con- 
tained a  small  quantity  of  turbid  fluid.  The 
liver  showed  on  sectic^n  gray,  wedge-shaped 
patches.  In  the  lungs  infarcts  the  size  of  a  pea 
were  found.  A  syringeful  of  blood  taken  from 
the  heart  of  this  animal  was  now  injected  un- 
der the  skin  of  the  back  of  a  second  rabbit. 
The  second  animal  died  in  forty  hours,  and  at 
the  necrops}-  nearly  the  same  pathological  con- 
ditions were  found,  only  that  the  peritonitis 
was  less  advanced.  Further  experiments 
showed  that  y^  drop  of  p3'aemic  blood  proved 
fatal  in  rabbits  in  one  hundred  and  twent_y-five 
hours.  All  subsequent  experiments  proved 
that  the  less  the  quantity  of  blood  injected  the 
longer  the  time  which  elapsed  before  death 
occurred,  but  where  the  quantity  was  reduced 
to  the  one-thousandth  part  of  a  drop  no  result 
followed.  On  microscopic  examination  cocci 
were  found  in  great  numbers  everywhere 
throughout  the  body,  and  more  especially  in 
the  parts  which  had  undergone  alterations 
visible  to  the  naked  e3^e. 

The  description  of  the  microbe  found  cor- 
responds with  the  staph3dococcus.  The  rela- 
tion of  the  microbes  to  the  blood-vessels  could 
be  seen  best  in  the  renal  capillaries  (Fig.  78). 
In  the  interior  of  the  vessel,  at  C,  is  a  dense 
deposit  of  micrococci  adherent  to  the  wall,  and 
inclosing  in  its  substance  a  number  of  red  blood-corpuscles.  '^J'lie  capillary 
stasis  is  either  due  to  the  power  of  the  microbes  of  causing  the  red  blood- 
corpuscles,  to  which  the}'  adhere,  to  stick  together,  or  their  propert^^  of  pro- 
ducing in  their  immediate  vicinity  coagulation  of  the  blood,  and  thus  cause 
thrombosis.  The  microbes  were  found  so  arranged  that  the}^  inclosed 
red  blood-corpuscles  in  the  capillary  vessels  of  all  the  organs  examined, 


Fig.  78.— Vessel  fkom  the 
Cortex  of  the  Kidney 
OF  A  Pyemic  Rabbit. 
X  700.    (Koch.)* 

A,  nuclei  of  the  vascular  wall ;  B, 
small  group  of  micrococci  between  blood- 
corpuscles  ;  C,  dense  masses  of  micro- 
cocci adherent  to  the  wall  and  inclosing 
blood-corpuscles;  D,  pairs  of  micrococci 
at  the  border  of  the  large  mass. 


*  Copied  from    "Traumatic   Infective   Diseases,"   by  permission  of  the  New  Sydenham 
Society,  London. 


BACTERTOLOGICAL    AND    EXPERIMENTAL    RESEARCHES.  837 

as,  for  example,  in  the  spleen  and  in  the  lungs.  Koch  believes  that  the 
large  metastatic  deposits  in  the  liver  and  in  the  lungs  do  not  arise  by 
gradual  growth  of  a  mass  of  micrococci,  as  in  Fig  78,  but  by  the  arrest 
of  large  groups  and  of  the  clots  associated  with  them;  in  other  words, 
by  true  embolism.  In  the  metastatic  deposits  an  extensive  development 
of  micrococci  occurs,  and  these  are  not  confined  to  the  vessels,  but 
invade  the  neighboring  tissues.  In  the  peritoneal  cavity  the  micrococci 
were  not  found  in  large  masses,  but  isolated,  in  pairs  or  in  small 
groups. 

In  the  vicinity  of  the  abscess  he  detected  the  microbes  in  the  walls 
of  veins,  and  their  passage  through  these  into  tlie  interior  of  the  vessels 
could  be  readil}^  discerned  in  many  places.  As  Koch  has  j^ointed  out, 
the  microbe  of  pyaemia  in  rabbits,  which  is  a  pus-microbe,  when  brought 
in  contact  with  tlie  red  blood-corpuscles,  increases  their  viscosity  and 
the}'  form  larger  or  small  coagula  in  the  blood.  The}'  can  thus  no 
longer  pass  through  the  minute  capillar}'  net-work,  but  are  arrested  in 
the  smaller  vessels.  From  the  point  of  infection  fresh  micrococci  pass 
constantly  into  the  blood,  and  also  individual  micrococci  will  become 
detached  from  these  small  thrombi  and  emboli,  and  mix  with  the  blood- 
stream. As  the  microbes  are  constantly  beiug  deposited  by  mural  im- 
plantation, their  number  in  the  circulating  blood  always  remains  relatively 
small.  Klein  described  a  micrococcus  of  pyaemia  in  mice.  Certain 
cocci  which  were  present  in  pork  proved  fatal  to  mice  in  about  a  week, 
producing  both  purulent  inflammation  at  the  point  of  injection  and 
metastatic  abscesses  in  the  lungs.  Inoculations  in  the  same  species  of 
animal  w  ith  pysemic  products  reproduced  the  disease  in  a  typical  manner. 
PawloAvsky  found  that  by  simultaneous  injection  of  sterilized  cinnabar, 
and  of  cultivation  of  staphylococcus  pyogenes  aureus  into  the  circula- 
tion, he  produced  abscesses  in  various  organs — in  fact,  the  typical  picture 
of  pyaemia.  The  presence  of  particles  of  foreign  bodies  rendered 
material  aid  in  the  development  of  metastatic  abscesses,  as  the  mere 
arrest  of  pus-microbes  in  the  circulation  without  them,  as  a  rule,  was 
not  found  sufficient  of  itself  to  lead  to  the  production  of  true  pyaemia. 
In  rabbits,  even,  the  introduction  of  a  large  quantity  of  a  culture  of 
pus-microbes  into  the  circulation  did  not  produce  pyaemia.  Twenty-four 
hours  after  the  injection  he  found  the  microbes  in  large  numbers  in  the 
pulmonar}'  and  other  capillaries,  but  after  forty-eight  hours  they  had  all 
disappeared  from  the  blood.  If  the  cocci  are  incorporated  in,  or  are 
attached  to,  an  embolus,  this  latter,  by  producing  alterations  in  the 
endothelia  of  the  blood-vessels  at  the  point  of  impaction,  create  a  locus 
viinoria  residt'ntise  favorable  to  the  growth  of  the  microbes.  In  the 
experiments  of   Pawlowsky,  the  particles  of  cinnabar  acted   upon  the 


338  tKINCIPLES   OF   SURGERY. 

endothelial  lining  of  the  capillary  vessels  in  the  same  mannei'  as  the 
fragments  of  a  thrombus,  hy  impairing  the  local  nutrition  of  the  tissues 
with  which  they  were  brought  in  contact. 

ETIOLOGY. 

If  p3'aBmia  can  be  artificially  produced  in  rabbits,  mice,  and  guinea- 
pigs  with  pus,  or  with  a  pure  cultivation  of  the  same  with  or  without 
the  presence  of  foreign  bodies,  the  same  local  conditions  are  first  pro- 
duced at  the  point  of  inoculation  which  invariably  precede  the  develop- 
ment of  pyaemia  in  man.  Some  of  the  veins  at  the  seat  of  primar}-  in- 
fection are  invaded  by  pus-microbes,  and  become  blocked  by  a  thrombus  ; 
this  thrombus  undergoes  puriform  softening;  small  fragments  containing 
pus-microbes  become  detached  and  are  washed  awa}^  and  enter  the 
general  circulation  as  emboli,  which,  when  they  become  arrested, 
establish  independent  centres  of  suppuration.  In  such  cases  the  same 
microbes  can  be  found  in  the  wound,  in  the  blood,  in  the  tissues  around 
the  abscess,  and  in  all  distant  pyaemic  products.  Although  the  strep- 
tococcus pyogenes  has  been  found  most  frequently  in  the  pus  at  the 
primary  seat  of  infection  and  in  the  metastatic  abscesses  of  pysemic 
patients,  there  can  be  but  little  doubt  that  any  of  the  pus-microbes, 
when  present  in  sufficient  quantity  in  the  blood,  can  produce  the  disease. 
The  occurrence  of  pyaemia  from  suppurating  wounds  or  abscesses  does 
not  depend  so  much  upon  the  kind  of  pus-microbes  xohich  have  caused  the 
primary  suppuration  as  upon  surrounding  circumstances.  The  location 
and  anatomical  structure  of  the  tissues,  in  which  the  jjrimary  infection 
has  taken  place,  exert  an  imp)ortant  influence  in  the  production  of  the 
disease. 

It  is  an  exceedingly  familiar  clinical  fact  that  suppurative  inflamma- 
tion of  the  medullary  tissue  in  bone  is  frequently  the  cause  of  p3'8emia. 
Acute  suppurative  osteom3^elitis,  without  direct  infection  through  a 
wound,  is  always  due  to  intra-vascular  infection — localization  of  pus- 
microbes  in  the  capillary  vessels  of  the  medullary  tissue.  The  microbes 
come  first  in  contact  with  the  endothelial  cells  when  mural  implantation 
has  taken  place,  and  the  coagulation  necrosis  which  follows  leads  to 
thrombosis.  The  products  of  the  intra-vascular  coagulation  necrosis 
furnish  a  most  fiivorable  nutrient  substance  for  the  growth  and  multipli- 
cation of  the  pus-microbes;  consequently  the  area  of  intra-vascular  in- 
fection is  rapidly  increased.  The  growth  of  the  tlirombus  in  a  proximal 
direction  soon  leads  to  extensive  thrombo-phlebitis,  and,  as  softening  of 
the  thrombus  takes  place,  to  embolism  and  metastatic  suppuration. 
Pyaemia  following  a  suppurative  inflammation  in  a  wound,  or  in  the 
course  of  a  phlegmonous  inflammation  of  the  connective  tissue,  is  the 


ETIOLOGY.  339 

i'esult  of  :ui  intection  willi  pus-microbes  which  penetrate  the  veins  from 
without.  The  pus-microbes,  coming  first  in  contact  with  the  outer  coats 
of  the  veins,  give  rise  to  phlebitis,  which  progresses  from  w'ithout  in- 
ward, and  which  is  foUowed  b}'  thrombosis  as  soon  as  the  intima  is 
reached.  The  intra- vase uhir  dissemination  of  the  pus-microbes  then 
lalies  place  in  the  same  manner  as  in  cases  of  primary  tlirombo-phlebitis. 
Ordinary  jyyogenic  microbes  may  and  do  cause  pysemia,  if  they  enter  the 
blood  incorporated  in,  or  attached  to^  fragments  of  an  infected  blood-clot, 
or  other  solid  materials,  which,  after  they  have  become  impacted  in  blood- 
vessels as  emboli,  prepare  the  soil  in  distant  organs  for  their  localization 
and  reproduction. 

The  importance  of  thrombosis  and  embolism,  as  essential  factors  in 
the  causation  of  pyemia,  has  been  clearly  established  b}^  clinical  obser- 
vation and  experimental  research.  Emboli  niaj'  originate  in  the  lym- 
phatic vessels  when  these  are  the  seat  of  invasion  b}^  pyogenic  microbes, 
which,  however,  is  very  seldom  the  case.  In  chronic  pj'aemia,  in  wdiicli 
multiple  metastatic  abscesses  are  formed,  embolism  takes  no  essential 
part  in  the  process ;  the  microbes  enter  the  blood-current  without  such  a 
vehicle,  and  are  brought  in  direct  contact  by  mural  implantation  with 
the  interior  lining  of  vessels  weakened  by  injur}',  or  other  local  and 
general  debilitating  influences.  Experimental  research  has  shown  con- 
clusivelj^  that  the  mere  introduction  of  pus-microbes  into  the  circulation 
is  not  necessarily,  or  even  usuall}',  followed  by  pygemia,  and  their  acci- 
dental entrance  in  the  course  of  a  suppurative  inflammation  is  not  alwaj's 
followed  by  serious  consequences.  There  can  be  no  doubt  that  some  pus- 
microbes  reach  the  circulation  in  nearly  every  case  of  suppuration,  but 
their  pathogenic  action  is  prevented,  or  neutralized,  by  an  adequate  resist- 
ance on  the  part  of  the  tissues  with  which  they  are  brought  in  contact  and 
their  rapid  elimination  through  healthy  excretory  organs.  A  limited 
nnmber  of  pus-microbes  injected  into  the  circulation  of  a  health}'  animal, 
or  accidentalh-  introduced  into  the  blood  of  an  otherwise  health}' person. 
are  effectively  disposed  of  by  the  white  blood-corpuscles.  If,  however, 
the  same  number  of  microbes  are  present  in  combination  with  fragments 
of  a  blood-clot,  the  infected  foreign  particles  produce  such  nutritive 
changes  in  the  tissues  surrounding  them  as  to  transform  them  into  a 
favorable  soil  for  the  pathogenic  action  of  the  microbes.  The  same 
happens  if  free  pus-microbes  localize  in  a  part  the  vitality  of  which  has 
been  previously  diminished  by  trauma,  or  antecedent  pathological 
changes,  which  constitute  a  locus  minoris  resistentise  for  the  growth  and 
multiplication  of  the  pus-microbes.  Pya?mia,  therefore,  must  be  looked 
upon  rather  as  a  serious  and  fatal  complication  of  suppurative  lesions 
than  an  independent  specific  disease.     The  immediate  causes  of  pyaemia 


340  PRINCIPLES   OF    SURGERY. 

are  the  formation  of  au  infected  thrombus  at  the  primary  seat  of  infec- 
tion and  disintegration  of  this  tlirombus  to  such  an  extent  that  frag- 
ments become  detached  and  are  conveyed  by  the  blood-current  to  distant 
organs,  where  tliey  are  arrested  in  the  smaller  arteries  as  emboli. 

Thrombosis. — A  thrombus  is  an  intra-vascular  blood-clot  locally 
formed  within  the  heart  or  a  blood-vessel,  and  the  process  by  which  it  is 
formed  is  called  "  thrombosis."  A  thrombus  is  called  uenous  if  it  occur 
in  a  vein,  arterial  if  it  form  in  an  artery.  A  red  thrombus  is  produced 
if  the  blood  coagulate  in  its  entirety,  while  a  white  thrombus  is  com- 
posed of  fibrin  exclusivel}'  or  the  fibrin  and  the  colorless  and  third  cor- 
puscles of  the  blood.  A  mural  thrombus  is  a  thrombus  w'hich  is  attached 
to  the  inner  surface  of  a  vessel-wall  without  occluding  the  entire  lumen 
of  the  vessel.  Notwithstanding  the  numerous  and  ingenious  experi- 
ments which  have  been  made  for  the  purpose  of  ascertaining  the  imme- 
diate cause  of  intra-vascular  coagulation  of  the  blood,  this  subject  awaits 
a  more  satis  factor}'  explanation  than  can  be  given  at  the  present  time. 
Richardson,  Bruecke,  and  Lister  have  shown  that  the  mere  mechanical 
interruption  to  the  flow  of  blood  in  a  vessel  is  not  a  sufficient  cause  of 
coagulation.  Blood  has  been  kept  in  a  fluid  condition  in  a  vessel 
between  two  ligatures  for  au  indefinite  period  of  time  in  the  living- 
tissues. 

Yirchow,  Cohnheim,  Baumgarten,  and  Zahn  maintain  that  the  color- 
less corpuscles  are  in  the  closest  manner  related  to  thrombus  formation. 
Zahii,  from  observations  on  the  living  mesentery-  of  the  frog,  found  that 
when  the  wall  of  a  vessel  was  injured  the  colorless  corpuscles  accumu- 
late around  the  injured  part,  constituting  what  he  calls  a  white  throm- 
bus. The  corpuscles  subsequently,  in  great  part,  disintegrate  and  give 
rise  to  a  granular  accumulation,  which,  by  its  action  upon  the  fibrinogen 
of  the  blood,  causes  a  precipitation  of  fibrin. 

Since  the  discovery  of  the  third  corpuscle,  or  heematoblast^  by 
Hayem  and  Bizzozero,  the  part  taken  by  this  element  of  the  blood  in 
the  process  of  coagulation  has  been  carefully  studied  by  Eberth  and 
Schimmelbusch.  The  third  corpuscle  possesses  a  peculiar  property  to 
adhere  to  an}'  foreign  bodj'  or  irregularit}'  of  surface  of  the  intima  of 
the  blood-vessels.  The  authors  just  quoted  found  that  when  a  vessel  is 
injured,  as  by  t3'ing  a  ligature  around  it  and  removing  this  in  a  quarter 
of  an  hour  afterward,  these  minute  blood-disks  manifest  a  peculiar  ten- 
dency to  adhere  to  the  injured  part  of  the  tunica  intiuia  and  to  each 
other,  forming  a  white  mural  thrombus.  The  process  by  which  mural 
implantation  of  the  third  corpuscle  takes  place  these  authors  call  conglu- 
tination^ the  mass  thus  formed  being  composed  primarily  and  exclusivel}' 
of  this  morphological  element  of  the  blood.     If  an  aseptic  thread  is 


ETIOLOGY.  341 

drawn  across  the  lumen  of  a  vessel  in  which  the  blood-current  is  moving, 
the  third  corpuscle  is  arrested  in  its  course  and  becomes  deposited  upon 
the  tliread,  which  in  time  becomes  the  centre  of  a  white  thrombus.  Con- 
glutination, under  sucli  circumstances,  is  a  purely  mechanical  process. 

Eberth  and  Schimmelbusch  demonstrated  by  their  experiments  that 
conglutination  is  most  liable  to  occur  where  irregularities  of  the  tunica 
intima  are  present.  If  b}'  a  trauma  inflammatorj^  or  degenerative 
changes  take  place,  the  endothelial  lining  of  a  blood-vessel  is  rendered 
rough  and  uneven  ;  conglutination  takes  place  first  at  the  points  which 
project  farthest  into  the  lumen  of  the  vessel,  because  here  the  projecting 
bodj-  encroaches  upon  the  axial  current,  which  conve3'S  the  third  cor- 
puscle. In  thrombosis  from  pathological  causes,  mural  implantation  of 
the  third  corpuscle  takes  place  upon  an  intima  roughened  by  inflamma- 
tory-or  degenerative  changes.  Thrombus  formation^  as  we  observe  it  in 
jyyaenna^  always  lakes  place  upon  a  vessel-wall  altered  by  the  action  of  pus- 
microbes.  The  form  of  thrombosis  intimately-  associated  with  the  etiology 
and  pathological  anatomy  of  pyiemia  occurs  in  a  vein  within  or  in  close 
proximity  to  the  primary  suppurative  lesion.  The  close  relationship  of 
phlebitis  to  pya?mia  was  well  understood  by  John  Hunter,  who  believed 
that  the  former  always  preceded  the  latter.  He  taught  that  the  phlebitis 
resulted  in  intra-venous  production  of  pus  and  the  formation  of  metas- 
tatic abscesses.  Cruveilhier.  on  the  other  hand,  regarded  thrombosis  as 
the  first  link  in  the  chain  of  pathological  conditions  in  pyaemia.  The 
idea  of  primary  thrombosis  as  a  cause  of  disease  was  carried  b}-  his 
pupils  so  far  that  nearly  all  inflammatory  processes  were  by  them  attrib- 
uted to  thrombotic  changes  in  small  veins  ;  not  only  inflammatory  lesions, 
but  even  tumors  were  supposed  to  originate  in  this  manner.  A  new  as- 
pect was  given  to  the  pathology  of  this  disease  b}'  the  careful  experi- 
mental investigations  of  Virchow  on  thrombosis  and  embolism.  He 
showed  that  the  metastatic  deposits  always  occurred  at  points  where 
vessels  had  been  blocked  by  an  embolus  derived  from  a  disintegrating 
thrombus.  In  the  light  of  recent  research  phlebitis  precedes  thrombus 
formation  at  the  primary-  seat  of  the  infection.  The  pus-microbes  which  are 
present  in  the  infected  tissues  permeate  the  vein-wall,  and  induce  inflam- 
matorj-  changes  characteristic  of  this  form  of  infection.  As  soon  as  the 
infection  has  reached  the  intima  this  structure  is  roughened,  and  upon 
the  projecting  points  conglutination  takes  place,  and  the  foundation  for 
thrombus  is  laid  by  a  pavement  composed  of  the  third  corpuscles  of 
the  blood.  Upon  this  surface  aggregation  of  the  colorless  corpuscles 
takes  place,  and,  as  these  structures  undergo  coagulation  necrosis,  fibrin 
is  formed  and  a  mural  thrombus  is  established. 

The  pus-microbes,  which  have  reached  the  interior  of  the  vein  through 


342  PRINCIPLES   OF    SURGERY. 

the  inflamed  vein-wall,  multipl}-  in  the  tliroml)us,  and  produce  here,  as 
elsewhere  under  similar  favorable  circumstances,  their  specific  patho- 
genic eflect.  The  thrombus  thus  formed  is  an  infected  thrombus  which 
precludes  the  possibility  of  its  removal  l)y  absorption.  With  an  in- 
crease of  the  intra-veuous  infection  coagulation  is  hastened,  and  a  red 
thrombus  soon  fills  the  entire  lumen  of  the  vein,  surrounded  by  a  zone 
composed  exclusively  of  blood-disks,  colorless  corpuscles,  and  fibrin, 
which  compose  its  mural  portion.  As  soon  as  the  lumen  of  the  vein  has 
been  completely  obstructed  the  conditions  for  coagulation  are  improved, 
and  the  thrombus  increases  in  size  in  both  directions.     The  contact  of 


■■■■■-■.■.  ^v.'--:-  '\y-^:^^m!'Mm 


Fig.  79.— Lamixated  Thkombtts  ijt  a  Vein.  The  Dark  Granular  Lay- 
ers ARE  Composed  of  Colorless  Blood-corpuscles  and  Fibrin  : 
the  Central.  Lighter  Portion,  of  Red  Corpuscles.  1:97.  {Birch- 
Hirschfeld. ) 

the  blood  with  the  dead,  infected  thrombus  results  in  coagulation,  and  in 
this  manner  layer  after  layer  is  added  to  the  thrombus.  If  thrombus 
formation  take  place  in  advance  of  the  primary  phlebitis,  inflammation 
of  the  vein-wall  follows  as  an  inevitable  consequence  from  the  presence 
of  the  infected  thrombus,  the  inflammatory  process  spreading  like  the 
infection  from  within  outward.  The  growth  of  a  thrombus  is  seldom 
arrested  in  a  central  direction  until  some  large  vein-trunk  is  reached, 
into  which  the  apex  of  the  thrombus  projects. 

The  blood-current  in  a  vein  into  which  the  apex  of  a  thrombus  from 
an  adjacent  vein  projects  frequently  arrests  its  proximal  extension,  but 


ETIOLOGY. 


343 


if  the  venous  circulation  is  impeded,  or  tlie  tlirombus  continues  to  grow 
by  the  addition  of  new  laj-ers,  in  spite  of  the  obstacles  presented,  one 
portion  after  another  of  a  vein  becomes  involved,  and  the  thrombus 
rapidlj'  increases  in  length  in  a  proximal  direction.  A  venous  thrombus 
in  a  pjaemic  patient  is  only  loosely  attached  to  the  vein-wall,  as  the 
pus-microbes  transform  the  white  corpuscles,  which  remain  after  coagu- 
lation has  occurred,  into  pus-corpuscles,  and  in  this  manner  softening 
and  disintegration  of  the  thrombus  are  accomplished.  If  a  thrombus,  at 
the  point  where  it  is  in  contact  with  the  venous  circulation  on  the  proxi- 
mal side,  become  sufficiently  softened,  fragments  become  detached  and 
are  carried  awa}'  by  the  venous  current  as  emboli. 

Embolism. — An  embolus  is  a  detached  thrombus, part  of  a  thrombus^  or 
any  foreign  substance  transported  by  the  arterial 
blood-current  to  its  place  of  impaction.  The  process 
or  act  by  ichich  this  is  accomplished  is  called  embolism. 
An  aseptic  embolus  produces  disturbances  at  the 
seat  of  impaction,  which  result  exclusivel)^  from  the 
sudden  interruption  of  the  blood-supply  to  the  tissues 
fed  b}'  the  obstructed  vessel.  The  effect  on  the  tis- 
sues is  the  same  as  though  the  vessel  had  been  tied 
with  an  aseptic  ligature.  Yirchow  found  that  aseptic 
caoutchouc  emboli,  introduced  into  the  right  side  of 
the  circulation  through  the  jugular  vein,  produced 
no  serious  trouble  after  their  impaction  in  the 
branches  of  the  pulmonary  artery. 

Pauum  ascertained,  b3'  his  experiments,  that 
small,  simple  emboli  in  the  pulmonar}' arter}^  become 
encysted.  The  emboli  of  foetal  cartilage  which 
Maas  introduced  into  the  jugular  vein  in  dogs  did 
no  damage  to  the  pulmonar}'  tissue,  and  not  onl}- 
retained   their  vitalit\"   but  became  the  nucleus  of 

a  temporary'  tumor.  An  aseptic  embolus,  derived  from  plastic  intra- 
vascular exudations  or  an  aseptic  thrombus,  affects  the  tissues  at 
the  seat  of  impaction  in  the  same  manner  as  the  aseptic  substances 
which  have  been  used  to  produce  embolism  artificially  in  animals. 
An  embolus  consisting  of  a  fragment  of  ayi  infected  thrombus,  as  is  the 
case  in  jnjsemia,  is  a  culture  medium  which  contains  the  same  microbes  as 
caused  the  primary  infection,  and  which  at  the  seat  of  impaction  estab- 
lishes an  independent  centre  of  infection,  which  etiologically  and  patho- 
logically is  identical  with  the  primary  invasion. 

The  embolic  origin  of  metastatic  abscesses  was  first  pointed  out  by 
Yirchow,  who,  at  the  same  time,  showed  that  the  emboli  are  always 


Fig.  80.— Thrombo- 
phlebitis.   i-Hillrotli.) 

A,  central  end  of  venous 
thrombus  projecting  into  a 
larger  vein-trunk ;  B,  vein- 
branch  not  closed  by  a 
thrombus. 


844  PRINCIPLES    OK    SURGERY. 

derived  Iroin  venous  thiouibi  undergoing  puriform  softening.  Tlie 
closure  of  :i  vessel  b}-  tlirombosis  is  always  a  slow,  gradual  process, 
while  the  obliteration  of  an  artery  by  an  embolus  is  the  work  of  a 
moment.  The  gradual  closure  of  a  vessel  by  the  slow  growth  of  a 
thrombus  is  not  attended  by  tlie  same  degree  of  disturbance  of  nutrition 
as  wlien  a  vessel  of  similar  size  is  suddenly  blocl^ed  by  tlie  impaction  of 
an  embolus.  Septic  thrombo-pldebitis  does  not  lead  at  once  to  eml)olism, 
as  new  layers  are  constantly  being  added  to  tlie  proximal  end  of  the 
thrombus,  from  where  the  fragments  which  constitute  the  emboli  are 
always  derived.  Embolism  only  occurs  if  the  proximal  end  of  the 
thrombus  has  become  sufficiently  softened  that  fragments  separate  spon- 
taneousl}^  and  enter  the  venous  circulation,  or  if  the  fragments  are 
washed  away  by  the  venous  current  from  a  projecting  thrombus.  As 
the  infected  thrombus  is  always  located  in  a  vein  within,  or  in  close 
proximity  to,  the  seat  of  primary  infection,  the  detached  fragments  or 
emboli  reach  the  right  side  of  the  heart  with  the  venous  blood,  and,  as 
the}''  are  usually  too  large  to  pass  through  the  pulmonary  capillaries, 
they  become  impacted  in  the  branches  of  the  pulmonary  arter3\  The 
lung  acts  as  a  filter^  and  is  therefore  the  most  frequent  seat  of  embolism 
and  metastatic  abscesses.  The  circulatory  disturbances  at  the  seat  of 
impaction  give  rise  to  pathological  conditions  which  are  characteristic 
of  embolism,  and  can  be  readily  recognized  in  the  examination  of  organs 
after  death.  The  area  of  tissue  affected  by  the  sudden  closure  of  a  vessel 
by  the  impaction  of  an  embolus  is  called  an  infarct,  and  the  process  which 
produced  the  pathological  changes  infarction.  Infarcts  are  abvays 
wedge-shaped,  the  apex  of  the  triangle  corresponding  to  the  location  of 
the  embolus,  and  the  base  to  the  tiltiinate  branches  of  the  obliterated,  vessel. 
Cohnheim  has  described  what  he  calls  a  terminal  arterj^,  by  which  is 
meant  one  whose  branches  inosculate  onl}^  with  those  of  the  corre- 
sponding vein,  one  which  is  devoid  of  collateral  anastomosis.  Such  are 
the  renal  and  splenic  arteries,  and,  in  a  less  complete  manner,  those  of 
the  brain^heart,  stomach,  and  lungs.  If  a  terminal  arter}^  in  the  kidney 
or  spleen  is  obstructed  collateral  circulation  cannot  be  established,  and 
necrosis  of  the  tissues  whi(;h  depend  on  the  closed  artery  for  their  blood- 
suppl}'  is  an  inevitable  consequence.  The  same  result  follows  embolism 
of  a  terminal  arter}'  in  the  spleen.  In  the  other  organs  which  have  been 
enumerated  the  terminal  arrangement  of  the  arteries  is  not  as  absolute, 
and  embolism  is  not  followed  by  necrosis  with  the  same  degree  of 
certainty,  as  circulation  cannot  be  restored,  under  favorable  circum- 
stances, by  collateral  branches.  The  first  effect  of  the  closure  of  an 
artery,  by  an  embolus  in  an}'  of  these  organs,  is  the  appearance  of  a 
wedge-shaped  area  of  ischtemia,  which  in  size  corresponds  to  the  size  of 


ETIOLOGY.  345 

the  vessel  obstructed.  It  may  be  so  sninll  that  it  can  hardly  be  detected 
by  the  naked  eye,  or  the  base  of  tlie  wedge  may  be  1^  inches  in  length. 
The  border  of  this  wedge-shaped  space  becomes  the  seat  of  active  hyper- 
semia,  the  surrounding  vessels  undergoing  rapid  dilatation.  The  liyper- 
a^mia  is  usually  so  intense  that  rhexis  takes  i)lace  and  the  parts  become 
infiltrated  with  blood ;  hence  the  expression  h senior rhagic  infarct. 

Hamilton  is  of  the  opinion  that  the  hasmorrhagic  infarcts  in  the  lung- 
are  not  caused  by  embolism,  but  by  rupture  of  small  vessels  and  haemor- 
rhage into  the  alveoli,  the  distribution  of  the  fine  branches  of  the  bronchi 
determining  the  shape  of  the  infarct.  Although  the  ultimate  branches 
of  the  pulmonary  artery  cannot  be  called  terminal  arteries,  in  the 
strictest  sense  implied  by  this  term,  if  the}'  become  suddenly  blocked  by 
an  embolus,  collateral  hypersemia  is  so  intense  that  haemorrhage  into  the 


Fig.  81.— Embolus  of  Branch  of  Pulmonary  Artery.    Hjemorrhagic  Infarction 
OF  Alveoli.    Chromic-Acid  Specimen.    1:1()0.    (Birch- Hirschfeld.) 

parenchyma    of  the    organ    frequently    takes    place, — a   condition    well 
represented  in  Fig.  81. 

In  Imemorrhagic  infarcts  of  the  lung  resulting  from  embolism  the 
tissues  involved  are  firmer  than  normal,  and,  on  section,  present  pneu- 
matic appearances,  which  are  due  to  infiltration  with  leucocytes  and 
extravasation  of  blood,  as  well  as  transudation  of  blood-plasma  through 
the  walls  of  the  liypera?mie  blood-vessels  surrounding  the  iscluvmic  area. 
As  the  einl)oli  usuall}'  lodge  in  the  peripheral  branches  of  the  pulmonary 
artery,  the  infarcts  are  most  frequently  located  near  the  surface  of  the 
lung.  Immediately  after  embolism  has  occurred  the  district  supplied  by 
the  obstructed  vessel  presents  an  aniemic  appearance,  which  soon  gives 
place  to  a  reddish  color,  resulting  from  the  haemorrhagic  infiltration.  As 
in  p3-aemia  the  embolus  conveys  from  the  primary  seat  of  infection  the 


346 


PRINCIPLES    OF    SURGERY. 


specific  microbes  of  suppuration,  it  becomes  the  centre  of  a  suppurative 
inflammation.  The  pus-microbes  multiply'  in  their  new  location  and  at 
once  induce  a  suppuratiA^e  arteritis,  and,  after  their  passage  through  the 
inflamed  vessel-wall,  the}'  attack  the  histological  elements  contained  in 


Fig  82.— I'Y^Mic  Abscess  of  Lung.    X  350.    {Hamilton.) 

A,  walls  of  alveoli ;  B,  effused,  small,  round  cells  ;  C,  fibrin  lying  in  alveolar  spaces ;  D,  cell  entangled  in  meshes 
of  same;  E.  E.  E,  masses  of  micrococcus  (staphylococcus)  lying  in  exudation. 

the  exudation,  which  breaks  down,  becomes  purulent,  and  is  converted 
into  an  abscess.  In  the  lung  the  leucocytes  which  are  present  in  the 
infarct  are  converted  into  pus-corpuscles,  and  the  interstitial  connective 
tissue  undergoes  necrosis  and  can  be  found  as  detached  shreds  in  the 
abscess. 


ETIOLOGY. 


3^7 


Embolism  and  metastatic  abscesses,  although  more  frequently  found 
in  the  lungs  in  p\-ifimia,  are  not  limited  to  this  organ.  To  explain  the 
occurrence  of  embolism  in  more  remote  organs,  as  the  kidne3S,  spleen, 
liver,  brain,  etc.,  we  must  assume  either  that  an  embolus  in  the  pulmonary 
arter}-  becomes  the  nucleus  of  a  thrombus,  which,  b^'  its  growth,  reaches 
across  the  pulmonarj'  capillaries  and  projects  into  the  pulmonarj^  vein, 
where  fragments  again  become  detached  and  enter  the  systemic  circula- 
tion, or  zoogioea  of  pus-microbes,  passing  the  first  filter  (the  lungs),  are 
arrested  in  the  capillaries  of  distant  organs,  or,  finally,  leucocj'tes  im- 
pregnated with  pus-microbes  serve  as  minute  emboli,  and,  after  their 
localization  in  distant  organs,  become  the  cause  of  metastatic  suppura- 


FiG.  83.— Coagulation  Necrosis  feom  a  Kidney  Infarct.    x300.    (Birch-Hirschfeld.) 

A,  zone  of  reactive  inflammation ;  B,  loss  of  nuclei  in  the  necrosed  epithelia.    (The  nuclei  of  connective- 
tissue  cells  are  in  part  preserved.) 

tion.  In  the  kidney  the  infarctions  appear  as  sharply  circumscribed 
areas  of  a  pale,  cream-3-ellow  color.  When  cut  into,  the  infarct  has  a 
wedge  shape,  the  narrow  end  pointing  to  the  hilus.  The  red  zone  is  not 
so  marked  as  in  infarctions  of  the  spleen,  and  the  greatest  vascularity  is 
in  the  direction  of  the  embolus.  As  in  infarcts  of  the  lung,  the  hy- 
persemic  zone  corresponds  to  the  vessels  nearest  the  ischemic  area. 
Extravasation  of  blood,  although  present,  is  never  so  marked  as  in  the 
lung.  The  epithelial  cells  within  the  hypersemic  zone  are  destroyed  by 
coagulation  necrosis,  and  if  the  embolus  is  aseptic  this  portion  of  the 
kidney  is  removed  by  molecular  degeneration  and  absorption,  leaving  a 
cicatrix  behind. 


348  PRINCIPLES    OF    SURGERY. 

Infarcts  of  the  kidney  occurring  in  pyaemia  are  converted  into 
abscesses  in  the  same  manner  as  in  the  lungs,  by  the  escape  of  pus- 
microbes  from  the  embolus  tlirougli  tlie  inflamed  arterial  wall  into  the 
tissues  starved  by  defective  blood-sup])l3^ 

SYMPTOMS    AND    DIAGNOSIS. 

As  a  wound  complication  p3'a?mia  never  occurs  before  suppuration 
has  taken  place,  seldom  before  the  seventh,  usually  about  the  ninth  to 
eleventh,  day  after  the  accident  or  operation,  if  it  is  the  result  of  a 
primary  infection  of  the  wound.  In  patients  threatened  with  pyaemia, 
an  ill-deiined  train  of  premonitor}^  symptoms  precede  the  actual  develop- 
ment of  the  disease  These  symptoms  apply  to  the  appearance  of  the 
wound  and  tlie  general  condition  of  the  patient.  The  onset  of  the 
disease  may  be  suspected  at  any  time  after  suppuration  has  occurred, 
when  evidences  of  serious  capillary  stasis  manifest  themselves  at  the 
seat  of  injury  or  operation.  The  thrombo-phlebitis  gives  rise  to  oedema; 
the  margins  of  the  wound  appear  pufled  and  elevated,  the  granulations 
pale  and  flabby  ;  suppuration,  which  may  have  been  profuse,  becomes 
scanty  ;  the  pus  changes  its  character,  and,  instead  of  a  yellowish,  cream- 
colored  fluid,  it  becomes  sanious,  serous,  or  sero-sanguinolent. 

Careful  inspection  of  the  parts  at  this  time  may  reveal  the  existence 
of  thrombosis  in  one  or  more  of  the  veins  leading  from  the  focus  of 
primary  infection.  The  general  premonitory  symptoms  are  indicated  by 
a  slight  degree  of  intoxication,  the  result  of  the  introduction  into  the 
circulation  of  pus-microbes  and  their  ptomaines,  from  the  primary  focus 
of  suppuration,  causing  a  slight  rise  in  the  temperature  and  a  general 
feeling  of  malaise,  thirst,  and  loss  of  appetite.  The  actual  development 
of  the  disease  is  initiated  by  a  well-marked  severe  chill  or  rigor,  which  lasts 
from  a  few  minutes  to  an  hour  or  more.  The  chill  resembles  a  malarial 
chill,  and  has  often  been  mistaken  and  treated  as  such.  Such  a  chill  in 
a  patient  suHering  from  a  suppurating  wound  or  abscess  is  always  an 
alarming  symptom.  It  is  an  entirely  subjective  symptom,  as  the  ther- 
mometer placed  in  the  axilla  during  the  algid  stage  indicates  a  rise  in 
the  temperature,  which  often  reaches  104°  to  105°  F.  before  the  patient 
ceases  shivering. 

Chills  have  been  artificially  produced  in  animals  b}-  the  introduction 
of  foreign  substances  into  the  circulation,  and  in  pyaemia  it  is  an  indica- 
tion that  fragments  of  an  infected  thrombus,  and  witli  them  a  large 
quantity  of  pus-microbes,  have  entered  the  circulation.  The  chill  may 
recur  at  regular  intervals  daily  or  every  other  day, — a  feature  which  may 
still  further  add  to  the  difficulty  in  making  a  differential  diagnosis 
between   pj-semia  and  malaria.     Usually,  however,  the  chill   recurs   at 


SYMPTOMS    AND    DIAGNOSIS.  349 

irregular  intervals,  one,  two,  or  three  times  a  clay,  as  a  rule,  increasing 
in  frequency,  and  often  in  intensity,  as  the  disease  progresses.  If,  for 
instance,  during  the  first  few  days  the  patient  has  one  chill  dail}',  and, 
after  a  few  days  two  or  more  during  the  same  time,  ever3'  additional 
chill  indicates  a  more  advanced  stage  of  intoxication,  and  an  increase  in 
the  number  of  metastatic  foci.  After  the  chill  the  fever  continues  for 
several  hours,  with  a  temperature  of  103°  to  104°  F.,  until  the  appear- 
ance of  profuse  perspiration,  when  the  temperature  falls  to  normal,  or 
even  a  little  below  that.  The  chill,  fever,  and  sweating  coming  in  the 
same  order  and  of  about  the  same  duration  as  in  malaria,  the  clinical 
picture  resembles  the  latter  almost  to  perfection,  and  on  this  account 
many  cases  of  pyaemia  have  been  mistaken  in  the  beginning  for  malaria, 
and  vice  versa. 

The  fever  which  attends  pysemia  always  is  of  an  intermittent  or  re- 
mittent type.  In  acute  pyaemia  the  chills  may  return  several  times 
during  twenty -four  hours,  the  temperature  between  them  showing  re- 
missions, but  seldom  returning  to  normal.  In  subacute  and  chronic 
cases  the  remissions  are  well  marked  betw^een  the  chills,  the  temperature 
often  sinking  below  normal.  Vomiting  and  diarrhoea  are  less  constant 
symptoms  than  in  septicaemia.  The  pulse  in  its  frequency  corresponds 
to  the  temperature  ;  its  force  is  always  reduced  by  the  depressing  eftect 
of  the  ptomaines  upon  the  heart.  Delirium  is  occasionally  present,  but, 
as  a  rule,  the  mind  is  clear  until  the  end.  The  yellowish  color  of  the 
skin,  almost  constantl}?  present  in  pyaemia,  has  been  attributed  to  icterus, 
resulting  from  metastatic  processes  in  the  liver;  but  in  the  majority  of 
cases  it  is  not  the  result  of  retention  and  absorption  of  bile,  but  is  caused 
by  destruction  of  red  blood-corpuscles  and  pigmentation  of  the  tissues 
with  the  coloring  material  thus  liberated.  It  is  an  icterus,  which,  on 
account  of  its  origin,  is  called  '■'•lisematogenous  icterus''''  The  metastatic 
deposits  in  the  kidnej^s  are  indicated  by  the  appearance  of  albumen  and 
sometimes  pus  in  the  urine. 

Metastatic  Suppuration. — Infarcts  in  one  or  more  of  the  internal 
organs  are  present  in  ever}'  case  of  pj'aemia,  and  suppuration  in  some  of 
the  large  cavities  is  of  frequent  occurrence.  In  reference  to  the  number 
of  secondary'  metastatic  foci  of  suppuration,  a  great  deal  depends  on  the 
clinical  form  which  the  disease  assumes.  In  the  acute  form,  which 
proves  fatal  within  one  to  three  weeks,  the  infarcts  are  numerous  and 
the  abscesses  quite  small,  while  in  some  of  the  infarcts  the  existence 
of  supi)uration  cannot  be  demonstrated  macroscopicall}'.  In  chronic 
P3'aemia,  in  which  life  is  prolonged  for  months,  and  sometimes  even  a 
year,  the  number  of  secondary  foci  are  few,  but  the}'  have  resulted  in 
the  formation  of  large  abscesses.     The  presence  of  infarcts  of  the  lung 


,S50  PHINCIPLES   OF    SURGERY. 

jire  imlicuUd  hy  symptoms  and  signs  which  point  to  circumscribed  foci 
of  inflamnuition  in  this  organ.  If  tlie  infarct  is  immediately  underneath 
the  pleura,  it  gives  rise  to  circumscribed  pleuritis  and  sharp,  lancinating 
pain  at  a  point  corresponding  to  the  location  of  the  infarct,  always  aggra- 
vated bj'  the  respiratory  movements.  In  such  cases  friction-sounds  can 
often  be  heard  over  the  infarct.  The  consolidation  of  the  tissues  in- 
volved by  the  infarct  by  inflammatory  infiltration  from  the  vessels  sur- 
iDiinding  it  is  attended  by  crepitant  rales,  bronchial  breathing,  and 
ilullness  on  percussion,  over  an  area  corresponding  to  the  size  of  the 
infarct.  A  pulmonary  abscess  which  takes  the  place  of  an  infarct  in- 
creases in  size  by  encroaching  upon  the  surrounding  tissues,  and  in 
chronic  cases  may  emi)ty  itself  into  a  bronchial  tube.  A  subpleural 
infarct,  infected  with  pus-microbes,  not  infreciuentl}^  leads  to  sui)purative 
pleuritis  and  empyema  by  the  extension  of  the  infection  from  the  lung- 
tissues  to  tlie  adjacent  pleura.  In  the  same  manner  a  suppurating 
infarct  of  the  lung  may  become  a  direct  cause  of  suppurative  pericar- 
ditis, and  pyocardium  if  its  location  is  adjacent  to  the  pericardium. 
The  onset  of  metastatic  foci  in  the  lungs  is  often  insidious,  and  even 
large  infarcts  often  occasion  only  slight  subjective  symptoms  and  ob- 
jective signs.  Embarrassed  breathing  should  admonish  the  attendant 
to  search  for  evidences  of  multiple  infarcts  of  the  lung.  Abscesses  in 
the  liver,  caused  by  septic  emboli,  vary  in  size  from  that  of  a  pea  to  an 
orange,  but  occasion  no  symptoms  unless  they  are  located  immediately 
underneath  the  serous  covering,  when  they  cause  localized  pain.  Embolic 
infarcts  in  the  kidneys  may  be  suspected  if  the  urine  contains  albumen, 
or  pus,  or  both.  The  spleen  is  always  enlarged  in  pyaemia,  but,  as  this 
is  the  case  in  all  acute  infective  processes,  the  presence  of  an  infarct  or 
abscess  is  only  to  be  suspected  if  the  symptoms,  especially  pain  and  cir- 
cumscribed tenderness,  point  to  the  existence  of  perisplenitis.  Enormous 
pyaemic  abscesses  often  develop  insidiously  and  without  pain,  or  the 
ordinary  symptoms  of  acute  inflammation  between  muscles  and  in  the 
subcutaneous  connective  tissue.  Metastatic  suppuration  in  p3'8emia 
takes  place  not  only  where  infarction  has  occurred,  but  also  in  localities 
where  the  existence  of  embolism  cannot  be  demonstrated  anatomically-, 
this  being  notably  the  case  in  joints  and  the  large  serous  cavities.  Sup- 
purative pericarditis,  pleuritis,  and  peritonitis  frequently  complicate 
acute,  rapidly-fatal  py.'emia.  Suppurative  synovitis,  multiple  or  limited 
to  one  joint,  is  a  frequent  complication,  both  in  acute  and  chronic 
pysemia.  Metastatic  suppuration  in  these  localities  develops  without 
demonstrable  infarcts,  and  occurs,  in  all  probability,  in  consequence  of 
mural  implantation  of  pus-microbes  or  infected  leucocj'tes  upon  the  wall 
of  capillary  vessels,  the  intima  of  which  has  been  damaged  b}-  ptomaines 


SYMPTOMS    AND    DIAGNOSIS. 


351 


held  in  solution  by  the  circulating  blood.  As  in  all  cases  of  p^'aemia 
pus-microbes  and  their  ptomaines  necessarily  constantly  enter  the  cir- 
culation from  the  primary  focus  of  infection,  they  prepare  the  soil  for 
the  reception  and  pathogenic  action  of  pus-microbes  in  the  vessels  and 
tissues  of  certain  organs,  more  especially  the  synovial  membrane  of 
joints  and  the  serous  membranes  lining  the  large  cavities.  Pyaemic 
abscesses,  when  well-developed,  always  contain  yellow  pus  of  the  con- 
sistence of  cream.  Examined  under  the  microscope,  such  pus  contains 
corpuscles  in  which  no  sign  of  a  nucleus  can  be  found. 

The  pus-microbes  arc  always  present  in  great  numbers,  both  within 
the  pus-corpuscles  and  in  the  pus-serum.  While  some  doubt  may  remain 
after  the  tirst  chill  as  to  the  nature  of  the  disease,  this  doubt  is  dispelled 
Avith  the  recurrence  of  the  chills.  In  acute  cases  the  ciiill  returns  once 
or  twice  daily,  but,  unlike  in  cases  of  malaria,  if  the  chill  is  of  daily 
occurrence,  it  does  not  come  at  a  fixed  time,  as  is  the  case  in  mnlnria. 
If   the  disease   does    not    culminate 

into   a  daily   chill,  the  temi)erature  /^ 

then   shows    an   irregular   remittent  .       .'  •,     -' 

type  of    fever.      The    patient   loses  ;     ■.'°°  °:° 

strength  and  flesh  rapidly,  and  the  .7  ;    '  ^  •  -     /"''•-  •': 

face  presents  the  color  of  a  mixture  •     •.   ;        ,  ''    ,,_^' 

of  the  hectic   flush  with  the  icteric  "^        L    ^"^^ 

hue.     While  the  pulse  at  first  rises 

only  to  100  to  120  beats  per  minute  "  " 

during  the  febrile  exacerbations,  it  ^^^  ^i.-rx^Mic  its.  showing  com- 
soon  remains  at  from  120  to  150  per  J^^^^^f^  JT^^'^^S^.  11 

minute.    Great  thirst  and  complete  ^lli'o'^^^f^l^r^f2^n1c:?e?r^^''''" 

loss    of    appetite    remain    constant 

s^-mptoms.  The  tongue  and  lii)s  are  dry,  diarrha\a  is  more  common 
as  septic  intoxication  advances,  and  the  stools  are  frequently  stained 
with  blood.  As  the  fotal  termination  approaches,  delirium  and  sopor 
come  on,  and  under  increasing  symptoms  of  depression  death  takes 
place  gradually  from  heart-failure,  or  suddenly  from  embolism  of  the 
pidmonary  artery.  In  chronic  cases  the  duration  of  the  disease  is 
sometimes  prolonged  for  months,  and  Billroth  relates  a  case  where 
the  i)atient  lived  for  a  year.  In  chronic  cases  the  chills  recur  at  long 
intervals,  and  the  fcA'er  assumes  a  remittent  type  between  them.  In 
still  another  class  of  chronic  p3'aemia  the  chills  ultimately  disappear, 
and  the  fever  assumes  a  mild,  continuous  t3pe,  while  the  patient  gradu- 
all}'  succumbs  to  decubitus,  amyloid  degeneration  of  internal  organs,  or 
a  slow  form  of  septic  intoxication. 


352  PRINCIPLES    OF    SUKGERY. 

PROGNOSIS. 

The  prognosis  of  pyjemia,  is  alvvuys  grave.  Acute  pj^femia,  in  spite 
of  all  treatment,  almost  without  exception  terminates  in  death  in  IVom 
one  to  two  weeks.  The  few  recoveries  which  have  been  reported  were 
cases  of  subacute  or  chronic  pyjiemia.  As  pyjvmia  is  not  a  priniar}-,  but 
secondary,  condition,  it  is  a  fatal  disease  from  the  very  beginning,  as 
during  its  commencement  transportation  of  infected  tissue  has  taken 
place  to  localities  inaccessible  to  radical  treatment.  In  acute  cases  death 
seldom  takes  place  before  the  end  of  the  first  week,  more  frequently  from 
the  second  to  the  end  of  the  third  week.  In  chronic  cases  not  compli- 
cated by  pulmonary-  infarcts,  the  metastatic  suppuration  in  parts  accessi- 
ble to  surgical  treatment  are  occasionally  amenable  to  successful  treat- 
ment, and  a  cure  can  be  obtained  after  a  long  and  lingering  illness. 
Prospects  of  a  successful  issue  in  chronic  cases  can  be  only  entertained 
when  the  disease  attacks  young  individuals  otherwise  in  good  health. 
The  prognosis  of  pyaemia  is  also  modified  by  the  location  of  the  primarj' 
focus  of  infection,  as  when  this  is  not  accessible  to  direct  treatment  the 
disease  will  progress  uninfluenced  by  general  treatment.  If,  on  the 
other  hand,  further  suppl}'  of  septic  material  from  the  primar}-  infection- 
atrium  can  be  prevented  b\'  a  prompt  removal  of  the  infected  tissues, 
one  of  the  most  important  indications  of  treatment  has  been  met,  and 
the  hope  of  a  favorable  termination  has  been  thereby  increased. 

PATHOLOGICAL     ANATOMY. 

The  pathological  changes  found  in  patients  who  have  died  of  pyaemia 
are  cliaracteristic.  The  primary'  focus  of  infection  may  no  longer  be 
present,  as  it  may  have  healed,  but,  as  a  rule,  this  has  not  occurred,  and 
examination  shows  a  suppurating  wound,  an  abscess,  an  osteomyelitic 
focus,  a  suppurating  phlebitis  or  sinus  phlebitis.  The  vein  in  which  the 
fatal  thrombus  formed  may  not  be  a  large  one  ;  indeed,  it  may  be  so 
small  as  to  elude  detection  b}-  macroscopical  examination.  If  the  imme- 
diate cause  of  the  py{emia,the  thrombosed  vein,  can  be  located,  it  will  be 
found  filled  with  a  softened,  loose  blood-clot,  which  is  very  variable  in 
length,  and  the  proximal  end  of  wdiich  projects  usually  into  the  lumen 
of  some  larger  vein-trunk  on  the  proximal  side.  The  vein-wall  itself  is 
in  a  state  of  suppurative  inflammation  that  prevents  the  formation  of 
firm  adhesions  between  the  thrombus  and  the  intima,  as  we  find  it  in 
cases  of  plastic  throrabo-phlebitis.  The  new^  histological  elements  that 
are  produced  by  the  inflammatory  process  are  at  once  converted  into 
pus-corpuscles,  and  some  of  these  are  distributed  through  the  substance 
of  the  blood-clot,  and  furnish  an  additional  cause  for  the  softening  and 
disintegration  of  the  coagulum.     The  infarcts  are  most  numerous  in  the 


PATHOLOGICAL    ANATOMY.  353 

lungs,  but  are  also  found  in  tlie  spleen,  kidne3'S,  and  liver.  An  embolus 
catches  in  an  arter3-  at  a  point  where  the  lumen  suddenl3'  becomes 
smaller,  which  is  the  case  where  the  vessel  bifurcates.  The  ('ml)olus, 
after  it  has  become  impacted,  becomes  the  nucleus  of  a  thrombus,  as  the 
blood  which  comes  in  contact  with  it  undergoes  coagulation,  and  in  this 
manner  la3"er  after  layer  are  added  on  each  side.  As  the  embolus  under 
these  circumstances  is  always  composed  of  dead  infected  material,  it 
causes  at  the  seat  of  impaction  a  s})ecific  inflammation,  which  in  every 
respect  represents  the  type  of  inflammation  at  the  primary'  seat  of  infec- 
tion. As  the  tissues  wJiich  are  in  immediate  contact  with  the  embolus  are 
the  coats  of  an  artery^  a  su]jpurative  arteritis  follows  the  impaction,  and 
as  soon  as  the  pus-microbes  have  passed  thi'ough  the  softened,  inflamed 
arterial  wall  the  infection  extends  to  the  tissues  weakened  b}^  the  sudden 
abstraction  of  blood  ;  that  is,  the  tissues  which  are  within  the  borders  of 
the  wedge-shaped  infarct.  The  h3'per8emic  zone  around  the  infarct  con- 
stitutes a  wall  of  protection  against  unlimited  extension  of  the  infection 
and  inflammation.  In  the  lungs  the  infarct  becomes  rai)idly  infiltrated 
with  the  products  of  inflammation  from  the  hj'persemic  zone,  which  gives 
rise  to  consolidation  of  that  portion  of  the  lung.  Suppuration  is 
attended  bj-  liquefaction  of  the  exudation,  and  the  infarct  is  transformed 
into  an  abscess. 

In  pyaemia  the  emboli  that  reach  the  systemic  circulation  are  smaller 
than  those  which  reach  the  pulmonary  arter}' ;  consequently  the  infarcts, 
as  a  rule,  in  the  kidney,  spleen,  liver,  and  other  distant  organs  are  smaller 
than  those  in  the  lungs.  In  metastatic  suppuration  without  embolism, 
in  the  strict  sense  in  which  this  word  has  been  heretofore  used,  the  pus- 
microbes  which  become  implanted  upon  capillary  walls,  changed  by  the 
action  of  pre-existing  ptomaines  diff"used  in  the  blood,  reach  and  infect 
the  para-vascular  tissues  and  the  interior  of  large  cavities,  thus  causing 
a  rapidlj'-spreading,  diffuse,  suppurative  inflammation.  In  metastatic 
suppurative  inflammation  of  the  cynovial  membrane  of  joints,  the  peri- 
toneum, pleura,  and  pericardium,  the  process  represents  all  the  essential 
features  of  a  specific  surface  inflammation,  characterized  b}^  rapid  exten- 
sion of  the  inflammation  over  the  whole  surface,  and  the  accumulation 
of  a  large  purulent  collection  in  a  short  time.  Microscopic  examination 
of  nearly  all  organs  in  fatal  cases  of  p^-eemia  reveals  the  existence  of 
coagulation  necrosis  resulting  from  the  action  of  pus-microbes  and  their 
ptomaines  upon  tissues  with  which  they  have  been  brought  in  direct  con- 
tact. The  spleen  is  always  enlarged  and  softened,  even  if  no  infarcts 
are  present.  The  heart  is  flabb}'  and  the  muscular  tissue  softened.  The 
intestinal  mucous  membrane  is  swollen,  vascular,  softened,  and  at  points 
shows   submucous  extravasation    from    rupture  of  capillary  vessels, — 


354  PRINCIPLES   OF    SURGERY. 

evidences  that  tliis  structure  has  also  become  the  seat  of  metastatic  inflaiH' 
matioii.  Embolism  of  cerebral  vessels  is  an  unusual  occurrence  in 
P3'8emia,  while  they  are  frequently  obstructed  by  emboli  which  become 
detached  from  valvular  vegetations  in  the  left  side  of  the  heart. 

TREATMENT. 

Before  the  use  of  antiseptics  in  surger}',  pyaemia  figured  largely 
as  the  cause  of  death  after  injuries  and  operations.  Only  twenty -live 
years  ago  a  large  percentage  of  the  surgical  patients  in  the  old,  in- 
fected, European  hospitals  died  from  tliis  disease.  Insignificant  injuries 
and  minor  operations  were  frequently  followed  by  this  fatal  complica- 
tion. At  present  it  is  a  source  of  pride  to  the  teachers  of  surgery,  if 
during  a  course  of  lectures  they  do  not  succeed  in  finding  a  case  for  clin- 
ical study  and  instruction.  In  hospitals  where  antiseptic  surgery  is 
thoroughly  and  conscientiously  practiced  the  disease  is  almost  unknown. 
Helpless  as  we  still  are  in  curing  the  disease,  as  surely  can  we  prevent 
it,  in  the  management  of  recent  injuries  or  intentional  wounds,  if  we  re- 
sort to  careful  and  eflScient  antiseptic  precautions.  The  premnlion  of 
supplication  in  a  wound  furnishes  absolute  pi'otection  against  p)ysemia. 
Again,  the  early  radical  treatment  of  suppurative  lesions  has  been  the 
means  of  diminishing  the  frequenc}'  of  pyaemia  from  causes  other  than 
wounds.  The  prophylactic  treatment  of  pyaemia  consists  in  preventing 
suppuration  in  wounds  by  antiseptic  means,  and  in  sterilizing  suppurating 
foci  before  septic  thrombo-phlebitis  has  occurred  by  early  incision,  anti- 
septic irrigation,  drainage,  and  in  maintaining  asep)ticity  under  antiseptic 
dressings. 

In  the  treatment  of  suppurating  wounds  a  great  deal  can  be  done 
toward  the  prevention  of  pyaemia  by  resorting  to  thorough  secondary 
disinfection,  and  in  guarding  against  tension  and  accumulation  of  the 
products  of  septic  inflammation  b}'  efficient  drainage,  or,  still  better,  by 
combining  drainage  with  permanent  irrigation.  Suppurative  osteom^-e- 
litis  should  be  treated  by  early  operative  measures,  not  only  for  the  pur- 
pose of  preventing  unnecessary  destruction  of  bone  and  of  relieving 
pain,  but  more  particularity  with  a  view  of  warding  off  this  fatal  compli- 
cation. Klebs  has  recently  made  the  suggestion  to  surgeons  that  the 
prophylactic  treatment  of  p^-aemia  should  be  carried  still  farther,  b^^ 
excising  such  veins  as  are  known  to  contain  infected  thrombi  before 
embolism  has  taken  place.  The  justifiability  and  advisability  of  such 
treatment  cannot  be  doubted,  and  surgeons  will  be  glad  to  adopt  this 
suggestion  in  cases  where  it  is  possible  to  asccrt.iin  the  location  of  the 
thrombosed  vein  or  veins,  and  where  such  an  operation  is  feasible  on  an- 
atomical grounds.     In  grave  cases  of  osteomj'elitis  an  operation  for  this 


TREATMENT.  355 

special  indication  would  often  make  it  necessary  to  amputate,  as  even 
the  most  thorough  scraping  out  of  the  infected  medullary  cavitj^  might 
fail  in  removing  all  of  the  infected  thrombi.  It  has  also  been  suggested 
to  interrupt  the  venous  circulation  in  one  of  the  principal  ver.ous  trunks 
of  a  limb  b}'  ligation,  for  the  purpose  of  preventing  mechanicall}-  the 
entrance  of  detached  fragments  of  a  thrombus  into  the  circulation  ;  but 
this  procedure  has  not  answered  the  expectations,  as  the  emboli  will 
reach  the  general  circulation  through  collateral  branches.  Removal  of 
the  infected  thrombi  b}'  anii)utation  or  resection  of  the  affected  portion 
of  a  vein  are  more  reliable  prophylactic  measures  than  ligation  in  the 
continuit}'  of  a  principal  vein-trunk  on  the  proximal  side  of  the  primary' 
seat  of  infection.  Detachment  of  fragments  of  a  disintegrating  throm- 
bus must  be  prevented  as  far  as  possible  by  securing  absolute  rest  for  the 
infected  part,  as  all  sudden  movements,  active  and  passive,  and  sudden 
disturbances  of  the  circulation  may  become  the  means  of  separation  of 
fragments,  and  their  transportation  as  emboli  into  the  circulation.  The 
curative  treatment  of  pyfemia,  medical  and  surgical,  is  unsatisfactory. 
Quinine,  natrum  benzoicum,  and  the  different  preparations  of  salicylic 
acid  have  been  used  quite  extensive!}'  in  the  treatment  of  the  fever  which 
attends  the  disease.  Antifehrin,  antipyrin^  and  other  drugs  of  the  same 
class  of  remedies  are  worse  than  useless,  as  the  favorable  effects  from  their 
antipy7-etic  action  are  inore  than  overbalanced  by  the  harm  they  do  in 
depressing  the  action  of  the  heart.  External  heat  and  the  internal  ad- 
ministration of  diffusible  stimulants  should  be  used  to  shorten  the  dura- 
tion of  the  rigors.  Alcoholic  stimulants  are  indicated  in  the  acute  and 
chronic  forms  of  the  disease. 

In  chronic  pyaemia  a  daily  tepid  bath  is  of  the  greatest  value.  In 
the  same  class  of  cases  it  is  of  the  utmost  importance  to  support  the 
patient's  strength  by  systematic  feeding  and  the  use  of  the  malt  bever- 
ages, such  as  beer,  ale,  and  porter,  with  a  view  of  prolonging  life  until 
the  primary  cause  is  eliminated  from  the  primarj^  and  secondar}^  depots 
of  infection,  spontaneously  or  by  surgical  treatment.  In  acute  cases  of 
pyaemia,  originating  from  a  wound  of  one  of  the  extremities,  or  from  acute 
suppurative  osteomyelitis  of  the  long  bones,  the  question  of  removal  of 
the  primar}^  focus  of  infection  by  amputation  will  present  itself. 

If,  from  a  study  of  the  symptoms,  it  become  apparent  that  multiple 
infarcts  exist  in  the  lung,  or  lungs,  and  other  organs,  amputation  is  not 
permissible,  as  it  would  onl^^  result  in  shortening  the  life  of  the  patient. 
The  jyropriefy  of  an  amputation  should  only  be  considered  in  the  begin- 
ning of  the  disease,  and  before  extensive  dissemination  of  the  purulent 
infection  by  embolism  has  taken  place.  In  a  suppurating,  compound 
fracture,  amputation  may  be  indicated  for  other  reasons  than  those  of  a 


856  PRINCIPLES   OF    SURGERY. 

threatened  ov  developed  attack  of  pyivniia.  Secondary  disinfection  of  a 
suppurating  ivound  with  excision  of  thrombo-phlebitic  veins,  where  this  is 
ponf^ible,  should  be  practiced  in  all  cases  of  pyfsmia  for  the  purpose  of 
preventing  or  limiting  general  dissemination  by  embolism.  In  chronic 
cases  the  secondary  metastatic  processes  should  receive  earl}^  and 
careful  attention. 

As  in  these  cases  the  metastatic  suppuration,  as  a  rule,  is  not  caused 
by  embolic  infarcts,  life  is  threatened  b}'  the  secondary  lesions,  from 
which  ptomaine  intoxication  is  ninintained,  and  from  Avhich  new  places 
ma}'  become  infected  l)y  localization  of  j^us-microbes  in  capillary  vessels 
weakened  b}'  the  action  of  ptomaines.  Suppurating  joints  are  incised, 
drained,  and  irrigated  under  strict  antiseptic  precautions,  and  if  the 
metastatic  suppuration  is  limited  to  a  single  joint  this  can  be  done  witli 
a  fair  prospect  of  a  favorable  result.  Purulent  collections  in  the  serous 
cavities  or  connective  tissue  are  dealt  with  in  a  similar  manner.  Careful 
attention  to  diet  and  the  sanitar}^  surroundings  of  the  patient,  combined 
with  energetic  surgical  treatment  of  the  suppurating  foci,  will,  at  least 
occasionally,  be  rewarded  by  an  ultimate  recovery. 

SEPTICO-PY^MIA. 

In  the  absence  of  more  accurate  knowledge  concerning  the  microbic 
cause  of  septicaemia,  we  must,  at  least  for  the  present,  assign  to  septi- 
caemia and  p3'aemia  the  same  bacteriological  cause.  That  pus-microbes 
can  produce  septicjemia,  when  introduced  into  the  circulation  in  sufficient 
quantity,  has  already  been  shown,  and  that  pus-microbes  have  been 
frequently  cultivated  from  septic  products  is  a  matter  of  demonstration  ; 
hence  the  disease,  if  not  identical  with  pyaemia,  from  a  bacteriological 
stand-point,  is  at  any  rate  closel}'  allied  to  it.  It  has  also  been  shown  that, 
in  case  the  life  of  septic  patients  is  prolonged  for  a  sufficient  length  of 
time,  the  metastatic  foci  of  inflammation  are  the  seat  of  incipient  suppu- 
ration ;  hence  such  cases  resemble  pyaemia  upon  a  pathological  basis. 
In  pyaemia,  after  cessation  of  the  rigors,  which  are  the  most  character- 
istic clinical  symptom  of  this  disease,  the  fever  resembles  septicaemia, 
and,  as  the  clinical  picture  thus  developed  rests  upon  pathological  con- 
ditions typical  of  pj'semia,  it  would  be  proper  to  apply  to  such  cases  the 
term  septico-pysemia.  For  the  same  etiological  and  pathological  reasons 
we  apply  the  same  term  to  septicaemia  in  which  post-mortem  examination 
reveals  the  presence  of  minute,  multiple,  suppurating  foci. 

Septico-pysemia  may  be  defined  as  a  condition  in  which  the  sj^mp- 
toms  indicate  the  presence  of  both  septicaemia  and  p^-aemia,  and  in  which 
the  post-mortem  appearances  point  to  septic  and  purulent  infection. 
Leube  described  such  a  combination  of  the  two  diseases,  which  as  yet  are 


SEPTICO-PY.EMIA.  357 

considered  as  distinct,  occurring  in  patients  in  whom  ie  Avas  unable  to 
trace  tlie  source  of  infection  from  witliout ;  hence  he  called  the  affection 
spontaneous  sejytico-jjysemia.  Litten,  on  the  other  hand,  in  similar  cases, 
was  always  able  to  locate  the  infection-atrium,  but  the  primar}'  infection 
at  the  time  acute  S3-mptoms  set  in  had  either  disappeared  or  its  location 
could  onlj'  be  ascertained  by  most  careful  examination.  Jiirgensen 
applied  to  these  cases  the  lengthy  compound  word  "  kryptogenetic- 
septico-pyaemia,^^  as  he  was  unable  to  find  a  tangible  infection-atrium. 
In  ia  recent  article  on  the  subject  he  gives  an  account  of  100  cases  that 
came  under  his  own  personal  observation.  The  patients  were  usually 
attacked  first  with  acute  phar^-ngitis,  and,  as  this  stage  was  generally 
attended  b}'  a  chill  and  a  general  feeling  of  malaise,  the  patients  generally 
attributed  the  onset  of  the  disease  to  exposure  to  cold.  In  most  cases 
the  general  infection  was  announced  by  a  severe  chill.  Rapid  loss  of 
strength  was  one  of  the  most  prominent  sj-mptoms  ;  the  patients  in  a 
few  hours  after  the  chill  became  utterly  prostrated.  The  sj-raptoms 
Avhich  pointed  to  local  processes  during  life  were  referred  most  frequentl}^ 
to  the  lungs,  liver,  spleen,  pleura,  heart,  and  the  long  bones.  Whether 
the  primary  infection  occurred  through  the  phar^-nx,  where  the  first 
S3'mptoms  were  manifested,  could  not  be  definitely  ascertained.  In  the 
acute  cases,  the  sj-mptoms  were  grave  from  the  beginning  and  increased 
in  intensity  as  the  infection  progressed,  while,  in  the  chronic  cases, 
infection  is  kept  up  from  some  suppurating  focus,  and  the  disease  may 
continue  for  several  years.  Subcutaneous  and  retinal  hemorrhagic 
extravasations  were  frequently  observed.  Post-mortem  examinations 
revealed  suppuration  in  some  of  the  internal  organs,  and  vascular 
changes  which  are  characteristic  of  sepsis. 

These  cases  may  be  compared  with  acute  suppurative  osteomj^elitis, 
where,  after  the  most  careful  inc^uirj'  and  the  most  scrutinizing  examina- 
tion, we  often  fail  in  furnishing  reliable  evidence  for  locating  the  primary 
source  of  infection.  It  is  possible  that  the  pus-microbes  enter  through 
an  intact  or  inflamed  mucous  membrane,  or  through  the  appendages  of 
the  skin,  and  that  they  remain  in  a  latent,  inactive  condition  until  a  weak 
point  is  created  somewhere  in  the  body,  where  they  localize  in  a  soil 
prepared  for  their  reproduction  and  pathogenic  action,  or,  what  is  more 
likely  the  case,  they  entered  through  an  abrasion  or  slight  lesion,  wdiich 
may  have  been  so  insignificant  that  the  patient  himself  failed  to  notice 
it,  and  produced  no  symptoms  until,  by  accident  or  disease,  a  proper 
soil  was  prepared  for  the  initiation  of  an  acute  attack  in  one  or  more  of 
the  internal  organs.  The  remote  dangers  which  may  follow  infection 
through  an  insignificant  wound,  or  from  a  small,  suppurating  focus, 
should  remind  the  surgeon  of  the  importance  of  treating  these  little 


358  PRINCIPLES   OF   SURGERY. 

ailments  with  tlie  necessary  care  and  attention,  and  by  so  doing  he  "will 
often  be  the  means  of  preventing  fatal  complications.  In  2  cases  of 
kryptogenetic  septico-p^'temia  that  have  come  under  my  own  observa- 
tion the  disease  was  complicated  by  ulcerative  endocarditis.  In  1  of 
these  cases  the  immediate  cause  of  death  was  gangrene  from  embolism 
of  the  popliteal  artery. 


CHAPTER  XIV. 

Erysipelas. 

Erysipelas  is  a  self-limited,  ucute,  non-suppurative  inflammation  of 
tlie  lymphatic  vessels  of  the  skin  or  mucous  membrane,  attended  by  red- 
ness and  a  continued  type  of  fever.  As  a  wound  complication  it  occurs 
independently-  of  suppuration,  and  in  its  uncomplicated  pure  form 
remains  as  a  superficial  affection,  the  inflammation  never  passing  beyond 
the  structures  of  the  skin  or  mucous  membrane. 

HISTORY    OF   ITS   MICROBIC    ORIGIN. 

The  contagiousness  of  erysipelas  has  been  recognized  for  centuries, 
and  on  this  account  early  attempts  were  made  to  include  it  among 
microbic  diseases.  In  1868  Hueter  maintained  that  erysipelas  and  hos- 
pital gangrene  were  identical  diseases  and  caused  by  the  same  micro- 
organism. Its  microbic  nature  was  again  made  the  subject  of  investi- 
gation in  1872,  when  Napveau  discovered  micrococci  in  the  blood  of 
erj'sipelatous  patients.  Wilde  detected  the  same  microbes  in  the  blood, 
but  asserted  that  similar  micro-organisms  could  be  found  in  the  pus  in 
wounds  from  which  the  er3'sipelas  developed. 

In  18T4  Recklinghausen  found  masses  of  micrococci  in  the  Ij'm- 
phatic  channels  in  the  inflamed  skin  at  the  border  of  an  erysipelatous 
inflammation.  Nearly  the  same  time  similar  observations  were  made 
by  Billroth.  Ehrlich,  Tillmanns,  and  Koch.  Tillmanns  produced  the 
disease  artificially  in  animals  b}'  injecting  subcutaneousl}-  the  serum  con- 
tained in  the  bulla  of  erysipelatous  skin. 

Koch  attempted  to  produce  the  disease  artificially  in  rabbits  with 
injections  of  difterent  putrid  fluids,  but  failed  until  he  made  inoculations 
with  mouse-dung  softened  in  distilled  water.  He  injected  the  material 
under  the  skin  of  the  ear,  and  produced  an  inflammation  which  in  its 
course  resembled  er3sipelas.  Tlie  swelling  and  redness  spread  slowly 
downward  from  the  point  of  inoculation.  On  the  fifth  da}'  it  had 
extended  as  far  as  the  root  of  the  ear.  The  ear  became  exceedingly 
vascular,  so  that  the  separate  vessels  could  no  longer  be  identified,  while 
the  tissues  were  softened  and  edematous.  The  animal  died  on  the  seventh 
day.  Blood  taken  from  the  heart  of  this  animal  produced  no  effect  in 
other  rabbits,     Xo  microbes  could  be  found  in  the  blood  or  in  any  other 

(359) 


360 


PRINCIPLES   OF    SURGERY. 


organ  except  the  affected  ear.  In  transverse  sections  of  the  ear  the 
blood-vessels  were  seen  to  be  markedl3'  dilated,  full  of  red  corpuscles, 
and  surrounded  by  the  nuclei  of  white  corpuscles.  Between  these  and 
the  cartilage-cells  bacilli  were  found. 

The  bacilli  were  present  close  to  the  cartilage  onl}-.     Here  thej^  were 


Fig.  85— Section  of  Ear  of  Rabbit  Parallel  to  Sttrface  of  Cartilage. 
The  Morbid  Process  Resembled  Erysipelas.    X  700.    {Koch.)* 

A,  ball-like  accumulation  of  bacilli ;  B,  accumulation  of  nuclei  above  the  layer  of  bacilli :  C, 
nuclei  of  flat  cells  connected  with  the  cartilage  below  the  layer  of  bacilli :  D.  bacilli  arranged  parallel 
to  each  other. 

found  in  large  clusters,  from  which  the  bacilli  radiate  in  all  directions. 
This  net-work  of  bacilli  extended  over  the  whole  cartilage  of  the  ear  on 
both  surfaces.  Inflammation  was  most  marked  in  the  vicinity  of  the 
bacilli, and,  consequentl}^,  in  the  absence  of  other  causes,  there  could  be 
no    doubt   that   the    erj^sipelatous   inflammation    was   caused   by  these 

*  Copied  from  "  Traumatic  Infective  Diseases,"  by  permission   of   the  New  Sydenham 
Society,  London. 


DESCRIPTION    OF    STREPTOCOCCUS   ERYSIPELATOSUS.  361 

microl)es.  Orth  found  micrococci  in  the  contents  of  the  bulloe  of  erysip- 
elas. Recklinghausen  and  Lukowsky  found  them  in  the  lymphatic  ves- 
sels and  the  connective-tissue  spaces  in  the  structures  aftected  by 
erysipelas.  Billroth  and  Elirlich  found  bacteria  not  only  in  the  lym- 
phatic vessels,  but  also  in  the  blood-vessels  of  the  inflamed  skin.  Till- 
manns  found  microbes  in  er^-sipelatous  skin,  and  Letzerich,  in  cases  of 
erysipelas  attacking  vaccination  wounds,  found  them  in  the  wound  itself, 
in  the  blood-vessels,  muscles,  liver,  spleen,  and  kidnej^s.  The  essential 
specific  cause  of  erj^sipelas  was  finallj'^  discovered  by  Fehleisen  in  1883. 
He  cultivated  the  microbe  from  erysipelatous  products,  and  demon- 
strated its  essential  etiological  relationship  to  erysipelas  by  producing 
the  disease  artificial]}',  in  animals  and  man,  by  inoculations  with  pure 
cultures.  From  the  morphological  appearance  of  the  microbe  and  its 
direct  etiological  bearing  to  erysipelas  he  called  it  the  streptococcus  of 
erysipelas.  With  pure  cultures  of  this  microbe  he  produced  b}'^  inocula- 
tions not  only  erysipelas  in  animals,  to  prove  its  specific  pathogenic 
qualities,  but  successful  inoculations  were  also  made  in  man  for  thera- 
peutic purposes, 

DESCRIPTION"  OF    STREPTOCOCCUS   ERYSIPELATOSUS. 

The  streptococcus  erj'sipelatosus,  discovered  by  Fehleisen,  when 
examined  under   the  microscope  appears  in   the 

form  of  chains,  the   links  of  which  are  minute       \    ...- "N.— -•'  "^     / 
cocci,  3  to  4  micromillimetres  in  diameter.  .vi.  L-*"''    / 

The  streptococcus  of  er3'sipelas  invades  the        J      — >. .-••.'^''^ 

superficial    l3-mphatic    channels    of    the    skin    or      (..,       ^^      '     '     \ 
mucous   membrane    exclusivel}",  but    it  can   also  *'•"••''  0    i-.,.,/" 

be  found  in  the  serum  contained  in  bulhe.     Each  *'" 

coccus,  when  it  is  about  to  divide,  becomes  larger  ^eryI^ii^^lTt^sus^  Pu^^^ 
and  oval,  and  soon  appears  made  up  of  two  hemi-  AxST'Mf  ^stained^with 
spherical  masses,  the  two  new  cocci  resulting  from  ^arUnT'  ^  ^^^'  ^^"""'' 
fission  of  the  old  one.  Morphologically,  the  strep- 
tococcus of  erysipelas  and  the  streptococcus  p3-ogenes  are  nearl}-  iden- 
tical, onl}^  that  the  cocci  of  er^'sipelas  are  somewhat  larger,  while  botli 
are  somewhat  smaller  than  the  staphylococci. 

CULTIVATION. 

This  microbe  can  be  readily  cultivated  in  bouillon  at  ordinary  room- 
temperature  ;  also  upon  gelatin,  agar-agar,  and  solidified  blood-serum. 
Upon  solid  nutrient  media  the  appearances  of  the  cultures  resemble  very 
strongl}^  those  of  streptococcus  pyogenes.  There  is  less  tendency, 
however,  to  the  formation  of  terraces   the  margin  is  thicker  and  more 


362 


PRINCIPLES    OF    SURGERY. 


irregular  in  outline,  and  the  appearance  of  the  growth  is  more  opaque  and 
whiter.  Rosenbach  mentions,  as  another  distinguishing  feature  between 
the  two,  that  the  culture  of  the  streptococcus  of  erysipelas  represents 
the  shape  of  a  fern,  while  the  outlines  of  the  cultures  of  the  pus-strepto- 
coccus describe  the  shape  of  an  acacia-leaf.  The  culture  appears  as  a 
ver}'  delicate  grayish-white  film.  The  growth  is  ver^'  slow,  and  the 
individual  colonies  remain  small.  The  streptococcus  of  erysipelas  does 
not  liquefy  gelatin.  The  microbe  of  erysipelas  grows  equally  well 
when  oxygen  is  excluded.  If  gelatin  is  inoculated 
by  puncturing  with  a  needle  charged  with  a  i^ure 
culture,  microscopical  colonies  can  be  seen  the  whole 
length  of  the  track  of  the  needle  at  the  end  of 
twenty-four  hours.  In  four  days  the  culture  has 
reached  the  height  of  development,  and  colonies  the 
size  of  a  grain  of  sand  to  that  of  a  pin's  head  occupy 
the  whole  length  of  the  needle-track. 

In  cultures  the  microbe  retains  its  pathogenic 
qualities  for  about  four  months. 

INOCULATION    EXPERIMENTS. 

Fehleisen  produced,  artificial!}',  typical  erj-sipe- 
las  in  rabbits  by  injecting  pure  cultures  \;nder  the 
skin  of  the  ear.  Koch  and  Gaff  ky  used  cultures 
grown  upon  solidified  blood-serum  and  inoculated 
9  rabbits.  In  8  of  these  typical  erysipelas  de- 
veloped, the  attack  lasting  from  six  to  twelve  daj'-s. 
Krause  obtained  positive  results  by  inoculat- 
ing gray  mice.  In  all  cases  where  the  inoculation 
proved  successful  the  erj'sipelatous  inflammation 
started  at  the  point  of  inoculation,  and  extended 
rapidly,  always  following  the  lymphatic  channels. 
In  Krause's  experiments  the  animals  died  after  three 
or  four  days,  even  when  only  a  minute  quantity  of 
the  culture  was  injected  under  the  skin  of  the  back.  Examination  of  the 
infected  tissues  after  death  showed  that  inflammation  followed  the 
invasion  of  the  microbes,  and  consequently  the  principal  pathological 
changes  were  found  Avithin  and  in  the  immediate  vicinity  of  the  Ij^mphatic 
channels. 

INOCULATION    FOR    THERAPEUTIC    PURPOSES. 

As  soon  as  it  was  demonstrated  experimentally  that  simple,  uncom- 
plicated erysipelas  is  a  disease  attended  by  but  little  danger  to  life,  the 
suggestion  was  near  that,  if  the  disease  could  be  artificially  produced  in 


\ 


Fig.  87.— Stale  Cttl- 
TURE  OF  Streptococ- 
cus OF  Erysipelas  in 
Gelatin  at  Ordi- 
nary Temperature 
OF  Room,  Four  Days 
Old,  Natural  Size. 
{Baumgarten.) 


INOCULATION    FOR    THERAPEUTIC   PURPOSES.  363 

man  by  inoculation  witli  pure  cultures,  the  local  and  general  conditions 
thus  produced  might  prove  useful  in  the  cure  or  amelioration  of  some 
diseases  not  amenable  to  operative  treatment  and  internal  medication. 
Of  7  persons  the  subjects  of  incurable  tumors,  inoculated  b)^  Fehleisen 
with  pure  cultures,  6  developed  typical  erysipelas  ;  in  the  seventh  case  the 
patient  had  passed  through  an  attack  of  erj-sipelas  only  a  few  weeks 
previously-,  and  was,  in  all  prol)ability,  still  protected  against  a  new 
attack.  This  patient  was  inoculated  a  second  time  with  a  negative 
result.  In  other  instances  a  second  inoculation  failed  after  a  successful 
inoculation.  The  period  of  incubation  was  fixed  at  from  fifteen  to  sixt}^- 
one  hours.  The  microbe  was  found  onl}-  in  the  lymphatic  vessels  and  con- 
nective-tissue spaces,  and  when  the  culture  was  pure  suppuration  was  never 
produced.  Fehleisen  has  seen,  by  this  treatment,  a  cancer  of  the  breast 
become  smaller,  a  lupus  disappear  almost  completely,  while  a  case  of 
fibro-sarcoma  and  another  of  sarcoma  were  not  materially  aflfected  b}^ 
this  method  of  treatment.  Janicke  and  Neisser  have  recorded  a  death 
from  erysipelas  thus  intentionally  produced  in  a  case  of  cancer  of  the 
breast  beyond  the  reach  of  an  operation.  At  the  necropsy  it  was  proved 
that  the  tumor  had  almost  completely  disappeared,  and  the  microscopical 
examination  of  portions  that  had  remained  appeared  to  show  that  the 
tumor-cells  had  been  destroyed  through  the  direct  action  of  the  microbes. 
Biedert  saw,  in  a  child  suffering  from  a  sarcoma  involving  the  posterior 
part  of  the  cavity  of  the  mouth  and  pharj-nx,  the  left  half  of  the  tongue, 
the  naso-pharyngeal  space,  and  the  right  orbit,  the  tumor  disappear 
almost  completely  during  an  attack  of  erysipelas.  Cases,  on  the  other 
hand,  have  been  reported  in  which,  after  an  accidental  or  intentional 
attack  of  er^'sipelas,  the  tumor  commenced  to  grow  more  rapidly. 
Neelsen  reports  a  case  of  carcinoma  of  the  breast,  in  which,  after  two 
severe  attacks  of  erysipelas,  the  tumor  not  only  commenced  to  grow 
faster,  but  at  the  same  time  the  regional  infection  progressed  also  more 
rapidly. 

Babtchinsky  made  the  accidental  discovery  that  the  microbe  of 
erj-sipelas  is  a  direct  antagonist  to  the  virus  of  diphtheria.  His  son, 
while  suftering  from  a  most  severe  attack  of  diphtheria,  was  suddenly 
attacked  b}'  erysipelas.  This  complication,  grave  of  itself,  seemed  to 
hasten  the  fatal  termination  of  the  case,  and  during  the  first  few  hours 
of  the  eruption  the  patient  was  much  worse.  But  the  next  day  the 
symptoms  had  much  improved,  and  the  patient  made  a  rapid  recovery. 
Following  this  indication  Babtchinsky  inoculated  a  second  case  of 
diphtheria  with  a  culture  of  the  microbe  of  erysipelas  grown  on  agar- 
agar,  and  with  an  equally  happy  result.  Since  this  time,  of  14  cases  of 
diphtheria  treated  with  these  inoculations,  12  resulted  in  recovery,  and, 


364  PRINCIPLES   OF    SURGERY. 

as  in  the  2  cases  resulting  fatally  the  inoculation  produced  no  effect, 
these  negative  results  onl}-  tend  to  confirm  tlie  efficacy  of  the  curative 
inoculations.  It  is  remarkable  that  in  all  of  the  cases  where  erysipelas 
was  produced  artificially  this  disease  pursued  a  mild  course,  and  the 
patients  recovered  rapidly  from  both  diseases. 

Schwimmer  gives  an  account  of  11  cases  of  lupus,  in  all  of  which 
no  improvement  was  observed  after  an  intercurrent  attack  of  erysipelas. 
In  a  case  of  keloid  an  attack  of  erysipelas  was  followed  by  marked 
improvement,  and  a  lii)oma  underwent  a  similar  favorable  change  from 
the  same  cause.  Syphilitic  lesions  he  saw  temporarily  benefited,  while 
the  erysipelas  had  no  effect  in  permanently  influencing  the  course  of  the 
disease. 

Bruess  gives  an  account  of  the  effect  of  erysipelas  on  tumors  in  22 
patients.  Among  these  3  cases  of  sarcoma  were  permanently  cured. 
Two  cases  of  multiple  keloid  after  burns  were  also  cured.  In  4  cases 
of  lymphoma  of  the  neck  some  of  the  glands  became  smaller  and  some 
disappeared.  In  5  cases  the  erysipelas  was  artificiall}^  produced  b}' 
inoculation  with  a  pure  culture.  In  3  cases  of  carcinoma  of  the  mamma 
1  was  not  influenced  by  the  disease,  1  became  one-half  smaller,  and  1  was 
reduced  to  a  small  induration  in  the  scar  the  size  of  a  pea.  A  multiple 
fibro-sarcoma  was  greatly  benefited,  while  an  orbital  sarcoma  was  not 
improved. 

In  view  of  the  uncertaint}^  of  the  result,  and  the  not  inconsiderable 
danger  which  attends  tlie  intentional  form  of  erysipelas  in  patients 
debilitated  by  antecedent  disease,  it  is  safe  to  predict  that  no  further 
inoculations  will  be  made  in  man  until,  perhaps,  future  research  will 
demonstrate  a  certain  specific  antagonistic  action  of  the  streptococcus 
of  er3'sipelas  against  some  other  pathogenic  microbes,  the  cause  of  grave 
diseases  not  amenable  to  successful  treatment  by  less  heroic  measures. 

MANNER   OF   INFECTION. 

An  intact  skin  or  mucous  membrane  furnishes  absolute  protection 
against  infection  with  the  streptococcus  of  erysipelas.  This  microbe 
cannot  reach  the  lymphatic  vessels  without  an  infection-atrium,  which 
may  be  a  small  abrasion,  a  wound,  blister,  ulcer, — in  fact,  any  breach  of 
continuity  in  the  skin  or  mucous  membrane.  Before  antiseptic  surger3' 
was  practiced,  infection  frequentl}^  occurred  through  accidental  or  inten- 
tional wounds.  Antiseptic  surgery  has  greatly  diminished  the  frequency' 
of  traumatic  erysipelas,  but  has  not  completely  eradicated  it,  as  an 
occasional  case  will  occur  in  the  hands  of  the  most  careful  antiseptic 
surgeons.  Even  before  the  microbic  cause  of  erysipelas  was  known, 
Trousseau,  one  of  the  closest  of  clinical  observers,  claimed  that  infection 


MANNER   OF   INFECTION.  365 

with  the  virus  of  erj^sipelfis  is  onl}'  possible  through  some  wound  or 
abrasion  of  the  skin  ;  the  latter  maj-  be  so  insignificant  as  to  be  unnotice- 
able  and  entirely  overlooked  by  both  patient  and  phj'sieian.  Idiopathic 
or  spontaneous  erN'sipelas,  so  called,  does  not  exist ;  every  case  of  ery- 
sipelas is  traumatic,  in  so  far  that  by  injury  or  disease  the  necessar}^ 
infection-atrium  must  be  created  through  which  the  streptococcus  can 
reach  the  lymphatic  vessels.  In  erysipelas  without  a  tangible  infection- 
atrium,  infection  occurs  through  a  minute  puncture  or  abrasion,  which 
ma}',  perhaps,  never  have  attracted  the  patient's  attention,  and  which 
has  become  invisible  at  the  time  the  disease  is  first  noticed.  Infection, 
however,  may  also  take  place  through  a  mucous  membrane,  through 
which  the  microbes  enter  the  tissues  in  the  same  manner  and  under  the 
same  conditions  as  when  infection  takes  place  through  the  skin.  One  of 
the  severest  cases  of  er3'sipelas  that  ever  came  under  my  observation 


Fig.  88.— Section  through  Skin  near  the  Margin  of  the  Erysipelatous 
Zone,    x  "00.    (Koch.) 

1,  1,  e.ach  a  lymphatic  vessel  filled  with  streptococci  in  chains. 

commenced  in  the  pharynx,  or  tonsils,  and,  as  the  symptoms  subsided 
here,  a  typical  and  severe  facial  erysipelas  developed.  As  the  patient 
was  suffering  at  the  same  time  from  secondary  syphilis,  it  is  probable 
that  the  streptococcus  of  erysipelas  entered  the  tissues  through  the 
secondary  syphilitic  lesions  in  the  phar^-nx.  In  the  tissues  the  strepto- 
coccus of  erysipelas  invades  the  Ijnnphatic  channels  exclusively,  and 
manifests  here  its  specific  pathogenic  qualities. 

The  erysipelatous  inflammation  is,  in  reality,  a  specific,  progressive 
lymphangitis,  the  para-lymphatic  tissues  becoming  affected  by  contiguit}'. 
Within  the  lymphatic  channels  the  microbe  multiplies,  and  diflfusion  of 
the  infection  takes  place  in  the  course  of  the  lymphatic  vessels,  but  does 
not  always  follow  in  the  course  of  the  lymph-stream.  The  lymphatic 
vessels  are  often  found  crowded  with  the  microbe,  which  is  destroyed  in 
a  short  time,  as  with  the  subsidence  of  the  inflammation  the  microbe 
disappears.     According  to  Koch,  and  Fehleisen,  the  microbe  is  always 


366  PRINCrPLES    OF    SURGERY. 

found  most  numorous  in  the  portion  of  the  skin  corresponding  to  the 
border  of  the  inflamed  area.  At  this  point  the  lymphatics  frequently 
:il)pear  completely  blocked  by  dense  colonies  of  this  microbe,  so  that  no 
lymph-corpuscles  can  be  seen  among  them.  As  the  inflammation  extends 
to  the  surrounding  connective  tissue,  some  of  the  microbes  leave  tlie 
lymphatics  and  enter  the  connective-tissue  si)aces,  where  they  come  in 
contact  with  the  inflammatory  exudation.  Within  the  lymphatic  vessels 
the  streptococci  are  found  l)etween  the  lym[)h  and  colorless  blood-cor- 
puscles ;  in  the  connective  tissue  they  are  found  also  within  the  proto- 
plasm of  leucocytes. 

Metsclinikofl'  maintains,  in  opposition  to  most  of  the  modern  au- 
thors, that  the  arrest  of  the  extension  of  the  erysipelatous  inflammation 
is  accomplished  by  phagocytosis.  The  accumulation  of  leucocytes 
in  the  inflamed  tissues  has,  undoubtedly,  a  salutary  effect  in  mechani- 
cally blocking  the  avenues  through  which  infection  takes  place  ;  but  as 
most  of  the  microbes  are  outside  of,  and  not  within,  the  leucocytes 
and  lymph-corpuscles,  it  is  difficult  to  conceive  how  limitation  of  the 
extension  of  the  infection  could  be  accomplished  solely  by  phagocytosis. 
The  microbes  have  a  very  short  existence  in  the  tissues  ;  the  inflammation 
which  the}^  initiate  continues  for  some  time  after  all  microbes  have  dis- 
appeared. The  ptomaines  which  microbes  secrete  produce  protoplasmic 
alteration  of  the  connective-tissue  cells  and  the  capillary  blood-vessels, 
Avhich  prolong  the  inflammation  be^^ond  the  period  when  the  tissues  are 
in  a  sterile  condition.  Others  have  claimed  that  self-limitation  of  ery- 
sipelas is  due  to  destruction  of  the  microbes  by  the  high  temperature 
which  attends  the  disease.  De  Simone  has  recently  shown  that  pure 
cultures  of  the  streptococcus  of  erysipelas  lose  their  power  of  reproduc- 
tion if  thej'^  are  exposed  for  two  da3^s  consecutively  to  a  temperature  of 
39.5°  to  41°  C.  Clinical  experience,  however,  has  demonstrated  conclu- 
sivel}'  that  erysipelas  is  not  arrested  in  its  course  by  a  temperature  of 
40°  C,  or  more.  It  appears  that  the  streptococcus  exhausts  the  soil  of 
the  nutrient  material  which  it  requires  for  its  growth  and  reproduction 
in  a  short  time.  In  the  blood-vessels  of  the  inflamed  skin  no  strepto- 
cocci can  be  found,  but  that  they  occasionally  enter  the  blood-vessels  is 
sufficiently  evident  from  the  occurrence  of  metastatic  erysipelas,  and  the 
direct  transmission  of  erysipelas  from  mother  to  foetus  by  infection 
through  the  placental  circulation.  As  the  streptococcus  of  erysipelas 
produces  its  pathogenic  effects  in  the  lymphatic  vessels,  and  diff"uses 
itself  through  these  channels  in  the  tissues,  it  becomes  obvious  that  in 
all  cases  infection  takes  place  as  soon  as  localization  is  eflfected  in  the 
superficial  l3"mphatic  structures,  or  in  the  spaces  contributary  to  them, 
and  in  direct  connection  with  an  infection-atrium. 


RELATION    OF    JERYSIPELAS  TO    PUERPERAL    FEVER.  367 

RELATION  OF  ERYSIPELAS  TO  PUERPERAL  FEVER. 
Obstetricians  recognized  tlie  danger  of  exposing  puerperal  women 
to  the  infection  wliich  might  emanate  from  er^^sipehitous  patients  long 
before  the  microbe  of  erysipelas  was  known.  Since  the  discovery  of  the 
microbe  by  Fehleisen,  this  subject  has  attracted  renewed  attention,  and 
positive  knowledge  has  accumulated  both  from  accurate  clinical  obser- 
vation and  from  the  fertile  and  more  positive  field  of  experimentation. 
Gusserow  asserted,  upon  the  basis  of  an  extensive  experience,  that  no 
direct  etiological  relations  exist  between  the  contagium  of  erysipelas  and 
puerperal  fever.  He  had  under  his  care  puerperal  women  suffering  from 
erysipelas  of  the  skin  without  any  serious  disturbances  following  in  the 
genital  tract.  In  10  other  cases,  one  of  them  occurring  during  an  epi- 
demic of  puerperal  fever,  the  erysipelas  was  observed  as  a  complication 
of  septic  affections  of  the  genital  organs.  Gusserow  claims  that  in  this 
case  it  cannot  be  claimed  that  erysipelas  could  have  caused  the  puerperal 
affection,  as  the  latter  preceded  the  former.  But  another  point  could  be 
raised,  as  it  might  be  claimed  that  the  septic  processes  should  be  made 
answerable  for  the  occurrence  of  erysipelas.  This  author  has  studied 
this  subject  also  by  way  of  experiment.  A  pure  culture  of  the  strepto- 
coccus erysipelatosus,  which  had  been  tested  and  found  reliable  in  pro- 
ducing erysipelas  by  the  usual  methods  of  inoculation,  was  injected  into 
the  peritoneal  cavity  of  2  rabbits  ;  in  2  others  it  was  applied  to  an 
open  wound  of  the  abdomen,  and  in  the  last  2  animals  it  was  injected 
into  the  subserous  connective  tissue  of  the  peritoneum.  In  all  of  these 
animals  no  effect  was  produced,  and  no  pathological  changes  were  detected 
at  the  point  of  injection  when  the  animals  were  killed,  some  time  after  the 
inoculation.  Gusserow  looks  upon  the  results  of  these  experiments,  if 
not  as  positive  proof,  nevertheless  as  strong  evidence  against  the  claim 
that  erysipelas  can  cause  puerperal  sepsis.  Winckel,  an  equally  reliable 
and  able  observer,  has  come  to  entirely'  opposite  conclusions.  He  culti- 
vated from  a  parametritic  abscess,  which  had  developed  after  childbed, 
Fehleisen's  streptococcus.  Injections  of  this  culture  into  rabbits  pro- 
duced tj-pical  erysipelas.  The  same  author  also  observed  erysipelas  fol- 
lowing in  a  puerperal  woman  suffering  from  suppurative  perimetritis, 
pleuritis,  and  metro-l3'mphangitis.  The  patient  died  on  the  thirteenth 
day.  The  starting-point  of  the  ei*ysipelas  could  be  traced  to  an  ulcer  of 
the  vulva.  Blood  taken  i'rom  the  right  side  of  the  heart  soon  after  death 
was  inoculated  upon  a  solid  nutrient  medium,  and  produced  a  culture  of 
the  streptococcus  of  erj'sipeias.  The  same  culture  was  obtained  by  in- 
oculations with  fluids  taken  from  the  peritoneal  and  pleural  cavities,  the 
uterus,  kidne3's,  and  the  liver.  In  3  cases  a  culture  thus  obtained  was 
injected  into  the  peritoneal  cavity  of  rabbits,  and  no  peritonitis  followed. 


368  PRINCIPLES   OF    SURGERY. 

Ill  1  ».'Xi)t'riineiit  the  injection  produced  supi)urative  peritonitis.  Guinea- 
pigs  proved  less  susceptible  to  in  lection  than  rabbits.  In  white  mice 
the  inoculations  were  invariably  i)rodiictive  of  a  fatal  disease.  From 
the  results  of  these  experiments  the  author  claims  that  the  virus  of  ery- 
sipelas is  one  of  the  most  virulent  puerperal  poisons,  and  believes  that 
llicy  prove  the  casual  relations  of  erysipelas  to  puerperal  sepsis. 

Doyen  also  found,  both  in  mild  and  severe  cases  of  puerperal  fever, 
a  streptococcus  similar  to  the  one  described  b}^  Rosenbach  and  Fehleisen. 
lie  made  some  inoculations  to  determine  the  relationship  between  puer- 
peral sepsis  and  erysipelas.  The  streptococcus  found  in  the  infected 
tissues  of  puerperal-fever  patients  caused  er3'sipelas,  and  the  streptococ- 
cus found  in  erysipelas  developed  puerperal  fever.  From  his  own  obser- 
vations and  experiments  the  author  arrived  at  the  conclusion  that  the 
microbe  of  puerperal  sepsis  is  the  same  as  that  of  erysipelas.  From  a 
clinical  and  bacteriological  stand-point  it  is  evident  that  puerperal  sepsis 
from  infection  with  the  streptococcus  of  erysipelas  can  only  occur  when 
the  streptococcus  is  brought  in  contact  with  an  absorl)ing  surface  in  the 
genital  tract;  but  when  this  takes  place,  and  the  microbes  reach  the  en- 
larged lymphatic  vessels  of  the  puerperal  uterus,  the  most  violent  and 
fatal  form  of  puerperal  sepsis  is  almost  certain  to  follow. 

RELATION    OF    ERYSIPELAS   TO   PHLEGMONOUS    INFLAMMATION    AND 

SUPPURATION. 

Some  difference  of  opinion  still  exists,  among  bacteriologists,  with 
regard  to  the  question  whether  the  streptococcus  of  erysipelas  possesses 
pyogenic  properties.  The  majority  of  those  Avho  have  studied  this 
subject  experimentally  do  not  consider  the  streptococcus  of  erysipelas  as 
a  pus-microbe,  and  assert  that  when  suppuration  takes  place  in  er3^sipelas 
it  is  the  result  of  a  secondary  infection  with  pus-microbes,  and,  on  this 
account,  look  upon  phlegmonous  inflammation  as  a  complication,  and  not 
as  a  condition  belonging  to  the  erysipelatous  process.  Hajeck  made 
careful  investigations  to  show  that  the  streptococcus  of  erysipelas  is 
neither  in  form  nor  culture  materially  different  from  the  streptococcus 
P3"0genes,  but  he  showed,  also,  that  in  51  cutaneous  or  subcutaneous  in- 
oculations with  a  pure  culture  of  the  streptococcus  of  erysipelas  in  rabbits 
the  result  was  always  a  superficial  migrating  dermatitis  which  resembled 
to  perfection  erysipelas  in  man,  Avhile  similar  injections  with  the  strepto- 
coccus of  pus  produced  a  more  intense  and  deeply-seated  inflammation, 
which  in  almost  ever}'  instance  terminated  in  suppuration.  The  diflTer- 
ence  in  the  action  of  the  two  microbes  on  the  tissues  plainly  demon- 
strated their  non-identit3^  Microscopical  examination  of  the  inflamed 
tissue  showed  a  still  more  important  difference  as  far  as  the  localization 


PHLEGMONOUS    INFLAMMATION    AND    SUPPURATION.  369 

and  local  diffusion  of  the  microbes  were  concerned.  Tlie  microbe  of 
er3^sipelas  was  alwaj-s  found  with  the  products  of  inflammation  xvithin 
the  li/mphatw  vessels^  and  only  exceptionall}'  in  the  connective-tissue 
spaces,  which  anatomically^  are  onl}'  a  part  of  the  lymphatic  sj'steni. 
The  pus  streptococcus  penetrates  the  tissues  more  deeply  ;  it  is  not  only 
found  in  tlie  l^'mphatic  vessels  and  connective-tissue  spKces,  but  it  mi- 
grates  beyond  the  lymphatic  channels  and  infects  different  kinds  of  tissue . 
thus  giving  rise  to  a  more  deeply-seated  and  more  intense  injlammation. 
The  streptococcus  of  erysipelas  is  found  only  exceptionalh'  in  the  im- 
mediate vicinity  of  blood-vessels  ;  ivhile  the  microbe  of  pus  can  always  be 
seen  arranged  in  radiate  lines  around  vessels  entering  the  adventitia,  the 
muscular  coat,  and  often  even  in  the  lumen  of  the  vessel.  In  man  the  same 
histological  differences  can  be  seen  in  the  tissues  the  seat  of  erysipelatous 
and  phlegmonous  inflammation  as  in  the  artificial  conditions  in  animals 
subjected  to  experiment,  and  the  same  pathological  differences  are  also 
constantly  found.  The  author  asserts  that  Fehleisen  was  in  error  when 
he  claimed  that  the  formation  of  abscesses  occurred  independently  of  the 
erysipelatous  infection.  He  affirms  that  in  rabbits  inoculated  with  the 
virus  of  erysipelas  after  the  acute  inflammation  has  subsided  circum- 
scribed small  nodules  which  remain  may  suppurate,  but  suppuration 
never  becomes  diffuse,  while  after  injection  with  cultures  of  the  strepto- 
coccus p3'0genes  the  inflammation  assumes  a  phlegmonous  type  and  the 
suppuration  is  always  more  diffuse.  Hajeck  maintains  that  under  certain 
circumstances  a  circumscribed  superficial  suppuration  can  also  take 
place  in  erysipelatous  inflammation  in  man.  When  suppuration  in  a 
joint  takes  place,  however,  it  is  not  caused  b}^  the  erysipelatous  infec- 
tion, but  is  due  to  the  presence  of  pus-microbes.  Eiselsberg,  Bonone, 
Bordini,  Passet,  and  Simone  are  of  the  opinion  that  the  streptococcus 
of  erysipelas  and  the  streptococcus  of  suppuration  do  not  differ  in  their 
pathogenic  effects. 

Smirnoff  found  in  1  case  of  erysipelas  the  specific  microbe  in  the 
metacarpo-phalangeal  joint  of  the  left  hand,  which  was  the  seat  of  the 
disease.  In  the  case  of  a  man  who  had  died  of  erysipelas,  enormous  col- 
onies of  the  streptococcus  were  found  in  the  right  shoulder  and  knee 
joints.  The  synovial  fluid  injected  into  rabbits  occasioned  erysipelas 
migrans. 

Rheiner  found  Fehleisen's  streptococcus  in  all  cases  of  traumatic 
erysipelas  which  he  examined,  but  was  unable  to  find  it  in  2  cases  of 
gangrenous  erysipelas  following  t3'phus.  In  these  cases  he  found  bacilli 
which  he  believed  were  identical  with  Klebs-Eberth's  bacillus  of  typhus. 

Kahlden,  after  a  careful  study  of  the  recent  literature  on  er^'sipelas, 
and  the  difference  in  opinion  on  the  pathogenic  properties  of  the  strepto- 

24 


370  PRINCIPLES   OF   SURGERY. 

coccus  erysipelatosus,  remarks  that  the  subtilit}"  in  the  differences 
between  the  morphology'  and  the  cultures  of  the  microbe  of  erj-sipelas 
and  the  streptococcus  of  suppuration  is  undoubtedly  the  reason  why  no 
uniformity  of  opinion  exists  in  regard  to  their  specific  pathogenic  effects, 
especially  as  to  the  possibility  of  Fehleisen's  streptococcus  producing 
suppuration.  To  this  I  might  add  that  not  ever}-  superficial  diffuse 
inflammation  of  the  skin  is  er3'sipelas,  and  not  ever}'  abscess  occurring 
during,  or  soon  after,  an  attack  of  erysipelas  should  be  considered  as  a 
product  of  the  erysipelatous  infection.  The  surgeon  will  do  well  to 
adhere  to  the  teachings  of  Fehleisen,  who  is  positive  in  his  assertion 
that  the  streptococcus  of  erysipelas  never  produces  suppuration^  until 
more  convincing  proof  shall  have  been  furnished  of  the  pathogenic 
identity-  of  the  streptococcus  of  er3'sipelas  and  the  streptococcus  of 
suppuration. 

SYMPTOMS   AND    DIAGNOSIS. 

Erysipelas,  like  most  of  the  acute  infectious  diseases,  has  no  well- 
marked  premonitory  stage,  the  attack  being  sudden  and  followed  b}'  all 
the  symptoms  which  usher  in  an  acute  febrile  affection.  The  period  of 
incubation  in  man  has  been  fixed  at  from  fifteen  to  sixt^'-one  hours  b}- 
the  inoculations  which  have  been  made  to  produce  the  disease  artificially 
for  therapeutic  purposes.  Inoculations  prove  successful  if  the  skin  is 
punctured  with  a  needle  the  point  of  which  had  been  dipped  into  a  pure 
culture  of  the  streptococcus.  Such  punctures  have  no  visible  lesion 
after  a  few  hours, — a  fact  which  readily  explains  the  disappearance  of  a 
visible  infection-atrium  at  the  time  the  disease  appears,  in  cases  of 
erysipelas  developing  without  a  demonstrable  breach  of  continuity  in 
the  skin. 

In  the  adult  the  disease  commences,  almost  without  exception,  with 
a  chill  which  sometimes  amounts  to  a  severe  rigor.  Nausea  and  vomiting 
are  often  present  during  the  first  few  hours.  The  chill  is  followed  by  a 
rise  in  the  temperature,  w^hich  in  a  few  hours  increases  to  104°  F.  or 
more.  The  fever  assumes  a  continuous  t^pe,  and  in  uncomplicated  cases 
the  difference  between  the  morning  and  ■evening  temperature  is  slight. 
Headache,  thirst,  and  complete  loss  of  appetite  are  constant  and  promi- 
nent s^-mptoms.  The  pulse  is  at  first  full  and  bounding  and  seldom 
exceeds  100  beats  per  minute.  In  severe  cases  delirium  is  present 
almost  from  the  beginning,  and  continues  until  the  fever  subsides. 
Almost  simultaneously  with  the  appearance  of  the  general  symptoms,  the 
skin  in  the  immediate  vicinitj^  of  the  infection-atrium  shows  evidences 
of  the  existence  of  a  superficial  inflammation.  The  patient  complains  of 
a  sense  of  tightness  in  the  part,  which  is  accompanied  by  a  burning  and 
itching  sensation. 


SYMPTOMS   AND    DIAGNOSIS.  371 

In  traumatic  erysipelas  the  wound  presents  no  changes  in  its  appear- 
ance ;  if  suppuration  is  present  the  purulent  dischai'ge  becomes  some- 
what diminished  in  quantity  and  the  pus  is  rendered  more  serous.  The 
skin  around  the  seat  of  infection  is  firmer  to  the  touch,  and  if  the 
er3'sipelas  has  started  from  a  wound  infection  has  occurred  from  a 
certain  portion  of  the  wound,  wliile  the  remainder  shows  no  evidences 
which  point  to  er^^sipelatous  inflammation.  The  skin  which  is  involved 
by  the  er^'sipelatous  inflammation  presents,  almost  from  the  beginning, 
a  characteristic  rose  or  crimson  color.  With  the  appearance  of  the 
tj'pical  discoloration  the  inflammator3'  exudation  has  reached  its  height. 
The  color  disappears  under  pressure,  but  upon  the  removal  of  the  press- 
ure no  depression  is  left,  showing  that  little  or  no  oedema  is  present. 
The  induration  of  the  skin  is  most  marked  at  the  border  of  the  erysipe- 
latous zone,  and  disappears  with  the  absorption  of  the  inflammatory 
product  and  the  return  of  the  natural  color  of  the  skin.  Tlie  margin  of 
the  zone  is  abrupt  and  distinct  on  the  side  of  the  healthy  skin.  The 
border  of  the  erysipelatous  zone  is  not  straight,  but  irregular,  and  often 
fan-like  projections  can  he  felt  which  project  into  the  healthy  skin,  and, 
when  present,  they  are  characteristic,  almost  jMthognomonic ,  of  this  form, 
of  dermatitis.  The  degree  of  swelling  varies  according  to  the  intensit}^ 
of  the  infection  and  the  anatomical  structure  of  the  part  involved. 

If  the  infection  is  intense  and  parts  are  implicated  which  are 
abundantly  supplied  with  loose  connective  tissue,  the  swelling  is  greater 
than  in  cases  where  the  infection  is  mild  or  the  skin  is  stretched  over 
firm,  resisting  parts.  In  facial  erysipelas,  for  instance,  the  swelling  is 
much  greater  around  the  orbits  than  in  the  scalp,  because  in  the  former 
locality  the  loose,  cellular,  connective  tissue  underneath  the  skin  becomes 
swollen  and  oedematous  from  the  escape  into  it  of  the  inflammatory^ 
transudation. 

The  specific  inflammation,  starting  from  the  point  of  infection, 
spreads  continuoush'  and  uninterrupted!}'  along  the  course  of  the  super- 
ficial lymphatics,  but  is  not  limited  to  the  direction  of  the  Ijmph-current. 
The  intra-lymphatic  diffusion  of  the  streptococcus  is  not  a  passive,  but 
an  active,  process.  As  this  microbe  is  non-motile,  its  transportation  in  a 
direction  opposite  to  the  lymph-stream  can  only  occur  by  its  reproduc- 
tion. The  lymph-current  in  most,  if  not  all,  of  the  inflamed  lymphatic 
vessels  is  temporarily  arrested  by  the  blocking  of  the  interior  of  the  lym- 
p)hatic  vessels  with  colonies  of  the  streptococcus  and  the  accumulation  of 
lymph-corpuscles;  consequently  the  colonies  become  fixed  points  from 
which  new  tissues  are  infected  by  their  increase  in  size  in  all  directions, 
owing  to  rapid  reproduction  of  the  microbe.  Tiie  fever  continues  until 
the  infection  comes  to  a  stand-still.     The  intensity  of  the  subjective 


372  PRINCIPLES   OF    SURGERY. 

symptoms  does  not  always  correspond  with  the  temperature,  as  patients 
may  feel  quite  well  when  the  temperature  registers  104°  to  105°  F., 
while  others  show  evidences  of  serious  disturbance  with  a  much  lower 
temperature.  Small  vesicles  and  large  bullae  usually  result  from  conflu- 
ence of  a  number  of  vesicles.  The  contents  of  these  blisters  are  first 
serous,  but  suppuration  may  follow  later  from  the  entrance  of  pus- 
microbes.     Bullae  with  haeraorrhagic  contents  denote  a  grave  attack. 

The  duration  of  erj'sipelas  is  extremel}^  variable.  Genuine  erysipelas 
may  run  a  typical  course  and  terminate  in  recover}''  in  two  days,  or  the 
disease  may  extend  over  a  period  of  two  weeks  or  more.  The  extent  of 
surface  successivelj^  invaded  determines  its  duration.  If  it  start  from 
a  wound  of  the  hand  it  ma}-  extend  along  the  forearm  and  arm  to  the 
shoulder,  from  here  along  the  back  to  one  or  both  of  the  lower  extremi- 
ties, and  before  such  a  large  territor}'  of  skin  has  passed  through  all  the 
stages  of  the  disease  more  than  four  weeks  may  elapse.  As  soon  as  the 
disease  ceases  to  migrate  the  general  symptoms  subside,  and  within  a 
few  days  the  skin  returns  to  its  normal  condition,  and  the  patient 
recovers  his  usual  health  in  a  remarkably  short  time, — a  fact  which  tends 
to  prove  that  er3'sipelas,  in  its  uncomplicated  form,  does  not  impair  the 
function  of  any  of  the  internal  organs  to  an}-  considerable  extent. 
Exfoliation  of  the  skin  is  a  usual  occurrence.  In  the  differential 
diagnosis  we  liave  to  consider  lympliangitis,  erythema,  phlegmonous 
inflammation,  and  throrabo-phlebitis.  In  lymphangitis  from  other  causes 
than  the  streptococcus  of  erysipelas  tlie  inflammation  follows  larger 
lymphatic  channels,  which  appear  as  red  lines,  and  seldom,  if  ever,  is  the 
skin  proper  inoculated  in  the  inflammatory  process,  while  erysipelas 
is  a  combination  of  lymphangitis  with  dermatitis.  Erythema  appears 
as  circumscribed  points  of  inflammation  in  the  skin  with  healthy  tissue 
between,  while,  on  the  other  hand,  erysipelas  shows  no  such  interruptions, 
the  inflammation  being  a  continuous,  uninterrupted  process  followed  by 
speedy  repair.  Phlegmonous  inflammation  is  accompanied  by  inflamma- 
tion of  the  skin,  which,  in  its  external  appearances,  closely  resembles 
erysipelas ;  but  the  differential  diagnosis  rests  on  the  location  of  the 
primary  inflammation,  which  is  always  the  superficial  lymphatics  of  the 
skin  in  erysipelas,  and  the  subcutaneous  tissue  in  phlegmonous  inflam- 
mation. In  phlegmonous  inflammation  the  deep-seated  inflammatory 
exudation  is  the  primary  pathological  condition,  and  the  lymphangitis 
follows  as  a  secondary  result,  while  in  erysipelas  the  primary  specific 
lymphangitis  and  dermatitis  are  primary  conditions,  and  if  the  subcu- 
taneous tissue  become  involved  later  on  it  must  be  regarded  as  a  com- 
plication, and  not  as  an  integral  part  of  the  disease.  Patients  suflfering 
from  erysipelas  complain  of  a  smarting,  burning,  or  itching  sensation  in 


CLINICAL    FORMS   OF    ERYSIPELAS.  373 

the  affected  skin ;  phlegmonous  inflammation  is  attended  by  severe 
pain,  which  is  of  a  tlirobbing  character.  Thrombo-phlebitis,  starting 
from  a  chronic  ulcer  of  the  leg,  has  often  been  mistaken  for  erysipelas, 
not  only  by  laymen,  but  also  by  phj^sicians.  Thrombo-phlebitis  is  often 
attended  by  inflammation  of  the  tissues  around  the  inflamed  vein  and  of 
the  superimposed  skin,  but  the  inflammation  follows  in  the  course  of  the 
vein,  and  not  in  the  course  of  lymphatics ;  at  the  same  time  the  vein  can 
be  felt  as  a  solid,  tender  cord. 

CLINICAL   FORMS   OF   ERYSIPELAS. 

The  clinical  forms  of  er3sipelas  are  identical  in  so  far  that  they  are 
all  caused  by  the  same  microbe,  and  that  the  disease  primarily  consists 
of  a  specific  l^-mphangitis  and  dermatitis;  but  the^' vary  greatl}',  accord- 
ing to  the  location  and  structure  of  the  part  affected,  the  intensity  of 
the  infection,  and  tlie  existence  of  complications. 

Erysipelas  Erythematosum. — This  is  the  mildest  form  of  erysipelas. 
It  is  described  as  ery thematic  because  the  affected  skin  shows  but  little 
swelling,  and  the  affection  appears  more  as  an  efflorescence  than  an 
inflammation.  No  bulljfi  form,  and  only  slight  exfoliation  takes  place 
during  convalescence. 

Erysipelas  Bullosum. — In  this  form  the  inflammation  of  the  skin  is 
more  intense  and  the  swelling  more  marked,  in  consequence  of  which 
blisters  or  bulla  form  underneath  the  cuticle.  The  pathological  condi- 
tion resembles  a  burn  in  the  second  degree.  Removal  of  the  cuticle 
leaves  the  papillary  layer  of  the  skin  exposed.  The  bullae  often  become 
the  seat  of  secondary  infection  with  pus-microbes,  which  transform  the 
serous  contents  into  pus.  From  such  superficial  foci  of  suppurative 
inflammation  mny  develop  what  has  been  termed — 

Phlegmonous  Inflammation. — As  we  are  not  in  possession  of  con- 
clusive proof  that  the  streptococcus  of  erysipelas  possesses  pj'Ogenic 
properties,  we  can  only  explain  the  occurrence  of  phlegmonous  inflam- 
mation of  the  tissues  underneath  the  skin  affected  by  erysipelatous 
inflammation  b}'  taking  it  for  granted  that  the  deep-seated  phlegmonous 
inflammation  is  caused  not  only  by  the  streptococcus  of  erysipelas,  but 
by  the  accidental  entrance  into  the  tissues  of  microbes  of  suppuration. 
As  soon  as  secondary  infection  with  pus-microbes  takes  place  the  clinical 
picture  of  erysipelas  is  overshadowed  or  obscured  by  the  suppurative 
inflammation.  The  typical  general  and  local  symptoms  which  char- 
acterize the  erysipelatous  inflammation  give  way  to  sjmptoms  which 
indicate  the  existence  of  a  diffuse  suppurative  inflammation.  The  tem- 
perature shows  greater  remissions,  and  the  pulse  becomes  more  rapid 
and  feeble.     The  tongue  is  often  red  and  dry,  while  all  of  the  remaining 


374  PRINCIPLES   OF    SURGERY. 

s3'^mptoms  point  to  intoxication  from  absorption  of  ptomaines  produced 
in  the  tissues  by  tiie  i)us-nHerobes.  The  swelling  of  the  part  affected  is 
no  longer  limited  to  exudation  into  the  substance  of  the  skin,  but  affects 
mainly  the  deep-seated  tissues. 

We  have  reason  to  believe  that  in  most,  if  not  in  all,  cases  of 
phlegmonous  erysipelas  the  secondarj'  infection  with  pus-microl)es  takes 
place  from  a  superficial  suppurating  focus  as  from  a  suppurating  bulla, 
and  that  the  microbes  from  here  invade  the  subcutaneous  connective 
tissue.  The  phlegmonous  inflammation  spreads  with  great  rapidity,  so 
that  in  a  few  da^^s  the  skin  of  an  entire  extremity  may  become  under- 
mined with  pus,  the  patient,  in  the  meantime,  having  complained  but 
little  of  pain.  Such  an  extremit}^  on  palpation  imparts  the  sensation 
of  a  partially  filled  diffuse  abscess-cavity.  The  external  appearances 
furnish,  often,  no  reliable  indications  of  the  extent  of  the  deep-seated 
destruction.  If  incisions  are  made  at  this  time  a  large  quantity  of  pus 
escapes,  mixed  with  shreds  of  necrosed  connective  tissue,  and  examina- 
tion reveals  extensive  destruction  of  the  subcutaneous  connective  tissue 
and  intermuscular  septa.  Phlegmonous  inflammation,  as  a  rule,  does 
not  attack  tissues  the  seat  of  an  erysipelatous  inflammation,  but  the 
tissues  weakened  b^'  this  disease  and  infected  with  pus-microbes.  A 
sudden  increase  in  the  temperature  of  patients  suffering  from  erysipelas 
is  often  the  first  symptom  which  commences  this  complication,  and  such 
an  occurrence  should  admonish  the  attendant  to  detect  it  early  in  order 
to  subject  it  to  timely  and  efficient  treatment. 

Erysipelas  Gangpaenosum. — This  is  an  exceedingl}^  grave  form  of 
erysipelas.  Most  of  the  authors  are  of  the  opinion  that  if  the  strepto- 
coccus of  erysipelas  multiplies  with  suflScient  rapidity,  in  the  interior  of 
the  Ij^mphatic  vessels  and  the  connective-tissue  spaces,  so  as  to  com- 
pletely' block  these  channels  by  its  growth,  a  sufficient  amount  of 
ptomaines  is  produced  to  cause  necrosis  of  the  tissues,  and  under  such 
circumstances  the  er3^sipelatous  inflammation  terminates  in  gangrene  of 
the  skin.  This  gangrene  ma}' take  in  circumscribed  multiple  patches,  so 
that  after  separation  and  elimination  of  the  dead  tissue  the  skin  presents 
a  cribriform  appearance,  or  it  may  involve  a  large  district  of  the  skin, 
and  then  give  rise  to  extensive  loss  of  this  structure  in  case  the  patient 
survives  the  disease.  As  the  gangrene  often  commences  in  the  portion 
of  skin  covered  by  bullae,  it  still  remains  an  open  question  whether  it 
results  from  the  action  of  the  streptococcus  of  erysipelas,  or  whether  it 
is  the  result  of  a  secondary  infection  with  pus-microbes.  Isolated 
patches  of  gangrene  of  the  skin  are  met  with  in  many  cases  that  termi- 
nate in  recovery,  but  extensive  gangrene  of  the  skin  is  alwa3^s  a  serious 
complication,  as  it  may  result  in  death  from  septicaemia,  or,  if  life  is  not 


CLINICAL    FORMS    OF    ERYSIPELAS.  375 

destro3-ed,  it  at  least  greatl}-  protracts  the  recoverj-jand  often  calls  for  a 
tedious  treatment  to  restore  the  lost  tissue  by  skin-graftins:. 

Erysipelas  Metastaticum. — B3-  metastatic  erj-sipelas  is  meant  the 
occurrence  of  an  erysipelatous  inflammation  in  an  organ  or  a  part  where 
the  process  developed  separately  from  the  primary  field  of  infection.  If, 
for  instance,  er^'sipelas  should  appear  in  an  extremity  opposite  to  the 
one  primaril}'^  affected,  without  extension  of  the  disease  across  the  skin 
of  the  trunk,  it  would  furnish  a  good  example  of  what  is  meant  by 
metastatic  erj'sipelas.  Again,  if  during  an  attack  of  erysipelas  of  one 
of  the  extremities  the  patient  should  be  attacked  with  s^-mptoms  of  men- 
ingitis, and  at  the  necrops}-  the  streptococcus  of  erysipelas  could  be 
demonstrated  in  the  inflamed  envelopes  of  the  brain,  this  would  furnish 
another  illustration  of  metastatic  er3sipelas.  Two  possibilities  present 
themselves  in  explaining  the  occurrence  of  metastatic  er3'sipelas.  In  the 
first  place,  colonies  of  the  streptococcus  in  an  active  condition  might 
reach  a  part  distant  from  the  erysipelatous  inflammation  with  the  13'mpli- 
current,  and,  meeting  with  favorable  conditions,  might  establish  an  addi- 
tional focus  of  erysipelatous  inflammation,  which,  of  course,  would  have 
to  be  necessaril3^  in  a  part  between  the  primary  field  of  infection  and 
the  termination  of  the  l3'mphatic  vessels  leading  from  the  infected  dis- 
trict. If  no  such  connection  can  be  established,  then  the  metastatic 
process  results  from  the  entrance  of  streptococci  in  an  active  condition 
into  the  circulation  and  their  localization  in  distant  parts  or  organs  by 
mural  implantation  upon  the  wall  of  capillar3'  vessels  prepared  for  their 
localization  and  reproduction.  In  most  instances  metastatic  er3'8ipelas 
is  of  such  an  embolic  origin. 

Erysipelas  Migrans. — Migration  of  the  inflammatory  process  is  one 
of  the  characteristic  clinical  features  of  er3'sipelas.  In  ordinar3'  cases 
migration  is  limited  to  the  anatomical  region  affected.  In  cases  of  facial 
erysipelas  the  disease  seldom  spreads  be3'ond  the  scalp,  and  in  er3'sipelas 
of  the  extremities  the  disease  usuall3'  subsides  after  it  has  extended  over 
an  extremit3'.  Migrating  er3^sipelas  is  that  form  of  the  disease  where 
the  er3-sipelatous  inflammation  extends  from  place  to  place,  and  from 
limb  to  limb.  I  have  seen  this  form  most  frequentl3'  in  infants,  starting 
from  the  umbilicus  or  the  external  genital  organs.  I  have  seen  it  start 
from  these  points,  ascend  in  an  upward  direction  along  the  anterior 
aspect  of  the  bod3',  and,  after  reaching  both  shoulders,  spread  to  the 
upper  extremities,  later  to  descend  down  the  back,  and  finally  terminate 
in  the  toes  after  traveling  nearl3'  over  the  whole  surface  of  the  bod3\ 
Er3'sipelas  of  the  extremities  or  trunk  never  extends  to  the  face  or  scalp, 
while,  in  exceptional  cases,  er3'sipelas  of  the  face  assumes  the  migrating 
form.    Migrating  erysipelas  is  usuall3-  attended  b3-  onl3- moderate  swelling 


37()  PRINCIPLES    OF    SURGERY. 

:uid  slight  constitutional  disturbances.  One  peculiarity  of  this  form 
of  erysipelas  is  that  the  same  regions  may  become  involved  a  second 
time. 

Erysipelas  Facialis. — This  is  the  so-called  spontaneous  or  idiopathic 
form  of  erysipelas,  as  in  most  cases  even  close  inspection  does  not  reveal 
the  existence  of  an  infection-atrium.  The  disease  usually  commences  in 
one  of  the  alae,  or  at  the  root  of  the  nose, — localities  where  minute  skin 
lesions  are  frequently  produced,  and  localities  which  nu)re  than  any 
other  part  of  the  face  are  exposed  to  infection  by  contact  As  far  as 
its  extension  is  concerned,  facial  er3'sipelas  pursues  the  most  t^jiical 
course.  The  inflammation  spreads  toward  the  cheek  and  orbit  on  the 
side  first  aflfected,  and  then  creeps  across  the  bridge  of  the  nose  to  the 
opposite  side,  to  foHow  a  similar  course  here.  About  the  second  ortliird 
day  it  reaches  the  forehead,  and  from  here  and  the  outer  margins  of  the 
orbits  it  invades  the  scalp,  to  terminate  usually  aljout  the  end  of  a  week 
at  the  nape  of  the  neck.  The  chin  and  anterior  aspect  of  the  neck 
never  become  affected  in  facial  er3^sipelas.  Facial  erysipelas  is  attended 
by  considerable  swelling,  the  eyes  being  often  completely  closed  bj-  the 
oedematous  lids.  Bullae  form  frequently  about  the  centre  of  the  cheeks 
and  the  forehead.  One  of  the  dangers  of  facial  erysipelas  consists  in 
the  direct  extension  of  the  erysipelatous  inflammation  from  the  skin 
along  the  blood-vessels  to  the  meninges  of  the  brain.  The  meningitis 
under  these  circumstances  is  not  a  metastatic  process,  but  the  result  of 
a  direct  extension  of  the  inflammation  from  the  skin  to  the  meninges, 
along  structures  which  connect  them  through  the  intervening  skull. 
Patients  who  have  suffered  from  facial  er^'sipelas  are  not  protected 
against  subsequent  attacks  ;  in  fact,  experience  has  shown  that  they  are 
more  prone  to  infection  in  the  future  than  persons  who  have  never 
suffered  from  this  disease.  If  the  bullae  suppurate,  there  is  always  danger 
arising  from  suppurative  throrabo-phlebitis,  suppurative  lei)to-meuin- 
gitis,  and  suppurative  encephalitis, — fatal  complications  plainly  attribu- 
table to  secondary  infection  with  pus-microbes. 

Traumatic  Erysipelas. — We  have  seen  that,  in  the  strict  sense  of  the 
word,  all  cases  of  erysipelns  are  traumatic  in  their  origin,  in  so  far  that 
infection  never  takes  place  through  an  intact  skin  or  mucous  membrane; 
consequently  the  disease  never  occurs  without  an  infection-atrium,  which 
may  be  a  wound  or  a  lesion  of  the  surface  through  which  the  strepto- 
coccus gains  entrance  into  the  lymphatic  channels.  The  expression 
"  traumatic  er^-sipelas"  is  still  retained  for  the  purpose  of  designating 
er^'sipelas  as  one  of  the  numerous  forms  of  wound  complications.  If  a 
recent  wound  is  infected  with  the  microbe  of  erysipelas  the  disease  de- 
velops within  fifteen  to  sixty-one  hours  after  the  accident  or  operation. 


PROGNOSIS.  377 

The  disease  ma^-  occur  in  consequence  of  later  infection  at  any  time 
before  cicatrization  is  completed,  as  granulations  furnish  no  absolute 
protection  against  infection.  I  have  seen  the  disease  originate  more 
frequently  in  granulating  than  in  recent  wounds, — a  strong  argument  in 
support  of  the  advice  that  full  antiseptic  precautions  should  not  be  relin- 
quished until  the  healing  process  is  completed,  if  the  patient  is  to  be  pro- 
tected against  an  attack  of  erysipelas.  Another  important  fact  should 
always  be  remembered  :  that  small  wounds  are  more  frequently  attacked 
by  erysipelas  than  large  wounds,  because  the  latter  receive  more  careful 
attention,  and  are,  as  a  rule,  subjected  to  more  rigid  antiseptic  treatment. 

PROGNOSIS. 

Simple  uncomplicated  erysipelas  is  not  a  fatal  disease  unless  it 
attacks  infants  or  persons  debilitated  b}-  age  or  antecedent  diseases. 
Death  is  caused  more  frequently  by  complications.  The  most  common 
fatal  complications  are  suppurative  inflammation  at  the  seat  of  erysipe- 
latous inflammation,  or  metastatic  suppuration  in  distant  parts  or  organs, 
resulting  from  secondar}-  inflammation  with  pus-microbes,  or,  finally,  ex- 
tension of  the  erysipelatous  inflammation  to  important  organs,  as  the 
brain  or  its  envelopes,  in  cases  of  facial  erysipelas,  or  the  occurrence  of 
metastatic  erysipelas  in  vital  organs  from  embolic  processes.  The  prog- 
nosis is,  thei'efore,  based  largely  upon  the  absence  or  presence  of  com- 
plications, which  must  be  carefully  sought  for  in  all  cases  where  general 
or  local  s3-mptoms  point  to  their  existence.  The  temperature,  pulse, 
and  condition  of  nervous  and  digestive  organs  furnish  important  and 
valuable  prognostic  indications. 

TREATMENT. 

The  number  of  specifics  which  at  diflerent  times  have  been  recom- 
mended in  the  local  and  general  treatment  of  er^'sipelas  must  throw 
doubt  upon  tiie  etticac}'  of  an}'  local  applications  or  internal  remedies 
in  arresting  the  further  progress  of  erysipelas.  At  the  same  time  it 
must  not  be  forgotten  that  uncomplicated  erysipelas  is  a  disease  which 
tends  to  spontaneous  recover}',  and  seldom  proves  fatal,  even  if  it  is  al- 
lowed to  pursue  its  own  course,  unaided  by  any  local  application  or  in- 
ternal medication.  The  erj'sipelatous  inflammation  is  of  short  duration, 
and  passes  through  its  diflerent  stages  uninfluenced  by  local  or  general 
treatment.  Since  its  microbic  origin  has  been  suspected  diff"erent  meth- 
ods of  treatment  have  been  recommended  to  arrest  the  further  progress 
of  the  disease  by  destroj'ing  or  rendering  inert  the  primarj'  cause. 
Hueter  aimed  at  the  destruction  of  the  specific  microbe  by  injecting 
at  diflerent  points  at  the  border  of  the  erysipelatous  zone  5  to  6  cubic 


378  PRINCIPLES   OF    SURGERY. 

centimetres  of  3-per-cent.  solution  of  Ccirbolic  acid.  This  method  of  treat- 
ment in  the  hands  of  others  has  been  followed  almost  without  exception 
by  negative  results.  It  is  possible  that  subcutaneous  injections  of  a 
1-to-lOOO  solution  of  corrosive  sublimate  in  non-toxic  doses  would  yield 
better  results.  The  continued  application  of  cold,  even  of  an  ice-bag, 
has  been  found  useless  in  arresting  the  disease.  As  it  has  been  found 
that  a  temperature  of  over  40°  C.  continued  for  two  days  has  at  least 
an  inlii])itory  effect  on  the  growth  of  the  streptococcus  of  erysipelas  in 
artificial  nutrient  media,  it  would  appear  rational  to  resort  to  hot  anti- 
septic compresses  in  the  local  treatment  of  erysipelas.  If  the  area 
involved  is  limited,  a  compress,  saturated  with  a  weak  hot  solution  of 
corrosive  sul)limute,  would  answer  a  most  admirable  purpose.  If  a  large 
surface  is  affected  some  of  the  weaker  germicidal  solutions  could  be  used 
in  the  same  manner.  Moisture  and  heat  relieve  also  the  burning,  smart- 
ing sensation  more  promptly  and  eflicientl}'  than  the  different  filth}'  oils 
and  salves  wliich  have  been  employed.  Application  of  tincture  of  iodine, 
muriated  tiucture  of  iron,  and  solutions  of  nitrate  of  silver  are  worse 
than  useless,  because  they  destroy  the  skin,  which  shoiild  be  carefully 
preserved  in  order  to  protect  the  patient  against  secondary  infection 
Avith  pus-microbes. 

Recently  Kraske  recommended  multiple  minute  incisions  or,  rather, 
scarifications  in  the  skin,  at  the  peripheral  zone  of  the  erysipelatous 
inflammation,  for  the  purpose  of  preventing  further  extension  of  the 
disease.  If  the  skin  is  first  rendered  aseptic,  and  subsequent  secondary 
infection  is  guarded  against  by  the  application  of  a  reliable  anti- 
septic, this  treatment  may  prove  valuable  in  modifjang  the  progress 
of  the  disease.  After  scarification  a  hot,  moist,  sublimated  compress 
should  be  applied,  to  be  immediately  replaced  bj'  another  wdien  removed. 
The  external  use  of  ichth3'ol,  so  highl}^  recommended  by  Nussbaum,  has 
proved  useless  in  my  hands,  both  in  relieving  suffering  and  in  prevent- 
ing the  extension  of  the  disease. 

Wolfler  has  recently  called  attention  to  the  value  of  the  mechanical 
treatment  of  erysipelas.  He  has  published  18  additional  cases  of  ery- 
sipelas treated  b}^  pressure  of  strongl^y  adhesive  plasters.  After  the 
plaster  is  applied  the  disease  extends  into  the  compressed  parts  of  the 
skin,  which  swell  considerably  and  remain  swollen  for  several  days,  and 
then  both  the  swelling  and  the  fever  diminish.  He  recommends  that  by 
way  of  precaution  a  second  line  should  be  commenced  several  centi- 
metres distant  from  the  first.  The  part  must  be  carefully  inspected  once 
or  twice  dail}-  in  order  to  detect  any  loosening  of  the  plaster.  Occa- 
sionally the  erysipelatous  inflammation  extends  in  diminished  intensit}'^ 
for  a  short  distance  bej'ond  the  first  line  of  plaster,  but  this  does  not 


TREATMENT.  379 

last  long.  This  method  of  treatment  is  at  least  harmless,  and  if  future 
experience  should  prove,  as  it  probably-  ^vill,  that  it  will  not  succeed  in 
arresting  the  local  extension  of  the  disease,  it  will  at  least  provide  an 
eflScient  protection  for  the  inflamed  skin. 

Phlegmonous  inflammation  and  metastatic  suppuration  should  be 
prevented,  as  far  as  possible,  by  the  emplo3'ment  of  such  measures  as 
will  guard  against  the  formation  of  suppurating  foci  in  the  inflamed  skin. 
Bulla?  should  be  evacuated  as  soon  as  they  form  by  puncturing  with  an 
aseptic  needle,  carefully  preserving  the  cuticle  as  a  protection  against 
the  entrance  of  pyogenic  microbes.  Infiltrated  air  should  not  reach  the 
inflamed  skin,  and  lor  this  purpose  it  should  be  covered  either  with  an 
antiseptic,  moist  compress,  or  a  thick  layer  of  antiseptic  cotton.  The 
skin  is  disinfected  in  advance  of  the  extension  of  the  disease,  and  is  sub- 
sequentl}'  protected  against  additional  infection  by  applying  a  hot,  moist, 
antiseptic  compress,  or  by  covering  it  with  antiseptic  absorbent  cotton. 
If  suppuration  take  place  in  the  interior  of  bullye  the  cuticle  should  be 
removed,  after  which  the  surface  is  carefull_y  disinfected  by  irrigation 
with  a  germicidal  solution,  followed  by  an  application  with  a  10-per-cent. 
solution  of  chloride  of  zinc,  and  further  infection  prevented  by  an  anti- 
septic dressing.  If  phlegmonous  inflammation  develop  in  spite  of  these 
prophylactic  measures,  early  and  free  incisions  are  made,  free  drainage 
established,  and  a  subsequent  treatment  followed  out  appropriate  for 
phlegmonous  inflammation  not  complicated  b}'  erysipelas.  Gangrene  of 
the  skin  is  to  be  treated  by  appl3'ing  a  hot  antiseptic  compress  until  the 
dead  tissue  is  eliminated,  when  the  defect  is  replaced  by  skin-grafting. 
Internal  medication  has  even  been  less  satisfactor}^  than  the  local  meas- 
ures in  the  treatment  of  er^^sipelas.  During  the  febrile  stage  the  admin- 
istration of  the  tincture  of  ferric  chloride  and  the  mineral  acids  does 
more  harm  than  good.  If  the  temperature  is  high,  a  daily  antipyretic 
dose  of  quinine  is  indicated,  and  exerts  a  favorable  influence  upon  the 
local  process  and  the  general  condition  of  the  patient.  If  the  patient 
is  restless  a  full  dose  of  Dover's  powder  should  be  given  at  bed-time. 
Sj^mptoms  of  prostration  are  met  earl}-  by  the  use  of  a  substantial  wine 
or  some  other  alcoholic  stimulant. 

Symptoms  of  collapse  are  treated  b}'  administering  internally  1^ 
grains  of  camphor  every  hour,  or  the  same  amount  of  the  drug  is 
dissolved  in  oil  of  sweet  almonds  and  injected  subcutaneouslj'  everv 
half-hour  or  hour  until  symptoms  of  intoxication,  delirium,  and  reduc- 
tion of  the  pulse  to  50  or  55  beats  per  zninute  are  produced.  The  cam- 
phor treatment  in  grave  cases  of  erysipelas  was  introduced  by  Pirogolf. 
and  has  yielded  excellent  results  when  the  threatening  symptoms  point 
to  an  enfeebled  heart. 


380  i'KINCIPLES   OF    SURGERY. 

ERYSIPELOID. 

A  new  form  of  infective  dermatitis,  which  in  many  respects  resembles 
erysipelas,  has  been  recently  described  by  Rosenbach  under  the  name  of 
*'  erysipeloid."  It  attacks  usuall}'  the  fingers  and  exposed  portion  of  the 
hand,  and  is  most  frequently  met  with  in  persons  who  handle  game  or 
dead  animals,  as  cooks,  butchers,  fish-dealers,  and  tanners.  The  affec- 
tion starts  from  some  minute  abrasion  of  the  skin  as  a  bluish-red  infiltra- 
tion, which  slowly  advances  in  an  upward  direction.  The  inflamed  parts 
are  the  scat  of  a  burning,  smarting  sensation.  While  the  skin  at  the 
l)oint  of  infection  returns  to  its  natural  condition  and  color,  the  zone  of 
infiltration  becomes  larger,  as  it  continues  to  spread  until  the  disease 
api)e:irs  to  exhaust  itself  in  the  course  of  from  one  to  three  weeks.  The 
infectious  material  which  produces  this  disease  is  contained  in  decom- 
posing animal  substniices.  Infection  may  take  in  any  abraded  part  of 
the  body  which  comes  in  contact  with  material  containing  the  virus.  The 
temperature  remains  normal,  and  the  general  health  is  not  affected.  The 
inflammation  travels  ver_y  slowly,  so  that  if  infection  take  place  in  the 
tip  of  a  finger  it  reaches  the  metacarpo-phalangeal  joint  in  about  eight 
dajs,  and  during  the  second  week  it  spreads  over  the  back  of  the  hand, 
from  where  an  adjacent  finger  may  become  affected,  the  extension  then 
taking  a  direction  opposite  to  the  lymph-current.  Repeated  experiments 
to  obtain  a  pure  culture  of  the  microbe  failed,  until  in  November,  1886, 
the  author  succeeded  in  cultivating  it  upon  gelatin  from  a  case  in  which 
the  disease  could  be  traced  to  infection  from  old  cheese. 

The  author  injected  a  pure  culture  under  the  skin  of  his  own  arm 
at  three  different  points.  After  forty -eight  hours  he  experienced  a 
smarting,  burning  sensation  at  the  points  of  injection  ;  at  the  same  time 
a  circumscribed  redness  appeared  around  each  puncture,  which  soon  be- 
came confluent.  On  the  fifth  day  each  puncture  was  surrounded  by  a 
zone  of  inflammation  the  size  of  a  silver  dollar,  somewhat  elevated  above 
the  niveau  of  the  surrounding  skin.  While  the  centre  of  this  red  patch 
became  pale,  the  zone  of  inflammation  continued  to  enlarge.  In  the  in- 
flamed skin  the  capillary  vessels  could  be  seen  dilated, — a  condition  of 
the  circulation  which  imparted  to  the  tissues  an  arterial  hue  with  a 
slight  tinge  of  brown,  while  inside  of  the  zone  the  color  was  a  livid 
brown.  In  the  skin  which  had  returned  to  its  norm;il  pale  color  slight 
suggillations  appeared,  as  though  some  of  the  red  blood-corpuscles  in  the 
tissues  had  been  destro3'ed  during  the  progress  of  the  disease.  The  in- 
flammation appeared  to  have  completely  subsided  on  the  eighth  day,  when 
the  smarting  sensation  returned,  and  a  new  zone  appeared  around  the 
old  one.  On  the  tenth  day  the  area  measured  in  its  transverse  diameter 
24  centimetres,  and  in  the  parallel  direction  of  the  arm  18  centimetres. 


ERYSIPELOID.  381 

After  this  the  affection  disappeared  permanentlj'.  During  all  this 
time  tlie  general  health  remained  unimpaired,  and  the  temperature 
varied  from  36.8^  to  3T.2°  C.  A  microscopical  examination  of  the  pure 
culture  showed  that  it  was  composed  of  swarms  and  heaps  of  irregular, 
round,  and  elongated  bodies  somewhat  larger  in  size  than  the  staph3do- 
coccus.  The  author  first  believed  that  these  bodies  were  cocci,  but  later 
he  saw  a  net-work  of  intertwining  threads,  and  decided  that  they  were 
thread-forming  microbes.  In  old  cultures  the  threads  were  verj'  abun- 
dant, and  arranged  in  everj'  possible  wa3-  and  direction.  These  threads 
appeared  as  though  branches  were  given  off,  but  on  closer  examination 
it  could  be  seen  that  no  organic  connection  existed  between  them.  Ter- 
minal spores  at  the  tips  of  the  threads  were  numerous  and  could  not  be 
stained.  Neither  the  microbes  nor  the  threads  manifested  motile  power 
in  the  culture,  or  when  suspended  in  water ;  a  gelatin  culture  became 
visible  on  the  fourth  day  as  a  delicate  cloud,  which  increased  in  size 
ver}'  slowly  at  a  temperature  of  20°  C.  The  older  cultures  change  into  a 
brownish-gra}'  color,  and  then  resemble  the  culture  of  the  bacillus  of 
septicaemia  in  mice.  In  cultures  4  months  old  the  growth  was  not 
entirel3'  suspended.  The  author,  as  j-et,  has  not  given  a  name  to  this 
microbe,  but  believes,  on  botanical  grounds,  that  it  belongs  to  the  "  clado- 
thrix  "  variety  of  micro-organisms.  He  wished  to  ascertain  the  action 
of  this  microbe  on  lupus,  but  in  several  cases  in  which  it  was  tried  the 
inoculations  failed.  Erysipeloid  is  a  harmless  form  of  infection,  and 
subsides  spontaneouslj"  in  the  course  of  two  or  three  weeks.  I  have 
seen  a  number  of  cases  in  persons  handling  fish  and  game,  Avhere  the 
affection  started  in  one  of  the  fingers,  extended  slowl}-  as  far  as  the  dor- 
sum of  the  hand,  and  then  gradually  invaded  an  adjacent  finger  and  the 
buck  of  the  hand  as  far  as  the  wrist.  In  the  cases  that  have  come  under 
my  observation  the  infiamniation  never  extended  be^'ond  the  wrist.  The 
disease  is  self-limited,  and  its  local  extension  is  not  arrested  by  an}- 
topical  applications. 


CHAPTER  XV. 

Tetanus. 

The  wound-infective  diseases  in  which  the  microbes  or  their  pto- 
maines act  upon  the  central  nervous  s_ystem  are  represented  by  tetanus 
and  hydrophobia.  The  specific  microbes  which  are  the  cause  of  these 
diseases  produce  no  gross  pathological  changes  in  the  brain  or  spinal 
cord,  but  the  minute  tissue  changes  cause  a  central  irritation,  which  is 
manifested  by  spasm  of  certain  definite  muscular  groups.  Tetanus  is  an 
infective  disease  in  which  the  specific  microbic  cause  exerts  its  patho- 
genic action  on  the  central  nervous  sj'stem,  and  which  is  clinically  char- 
acterized by  spasm  and  rigidit}^  of  definite  muscular  groups. 

BACTERIOLOGICAL    STUDIES. 

The  classification  of  tetanus  with  the  infectious  diseases  is  of  recent 
date,  but  the  infectious  nature  of  the  disease  was  well  known  and  estab- 
lished before  the  discovery  of  the  bacillus  tetani.  In  1859Betoli  related 
the  case  of  a  bull  that  died  of  tetanus  after  castration.  Several  slaves 
ate  some  of  the  flesh  of  the  dead  animal,  and  of  these  3  were  (in  a  few 
days)  seized  with  tetanus  and  2  of  them  died.  He  adds,  further,  that 
in  Brazil,  where  this  occurred,  the  flesh  of  animals  dead  of  tetanus  is 
generall}'  regarded  as  capable  of  transmitting  the  disease.  In  18V0 
Auger  reported  a  case  in  which  a  horse  had  spontaneous  tetanus,  after 
which  3  puppies  which  had  been  in  the  same  stable  were  also  affected. 
Larger,  in  1853,  saw  a  woman  who  had  a  fall  while  cleaning  a  farm-yard, 
causing  a  slight  wound  of  the  elbow.  Four  weeks  later  she  was  seized 
with  tetanus,  and  on  investigation  it  was  found  that  a  horse  affected 
with  that  disease  had  been  in  a  stable  opening  into  the  yard  where  she 
fell.  He  also  mentions  another  circumstance  which  strongly  points  to 
the  infectious  nature  of  tetanus.  In  a  small  village,  where  tetanus  was 
previousl}^  unknown.  5  cases  appeared  in  eighteen  months  under  quite 
different  chmatic  conditions.  Of  these,  1  had  been  taken  to  a  hospital, 
after  which  2  others  in  the  same  ward  became  aff"ected  with  the  disease. 
In  1884  Carle  and  Rattone  produced  the  disease  artificiallj- in  animals  by 
inoculations  with  pus  from  tetanic  patients.  Nearly  at  the  same  time 
the  real  microbic  cause  of  tetanus  was  discovered  by  Nicolaier  and 
Rosenbach.     Nicolaier  showed   the  exogenous  origin  of  the  disease  by 

(383) 


384  PRINCIPLES   OF    SURGERY. 

finding  a  bacillus  in  earth,  which  produced  tetanus  in  animals  when 
injected  into  the  tissues,  llosenbach  found  the  same  bacillus  in  the  pus 
of  a  patient  suffering  from  traumatic  tetanus.  The  identity-  of  the 
bacillus  of  tetanus  with  Nicolaier's  bacillus  of  earth  tetanus  was  demon- 
strated in  Koch's  laboratory,  April  10,  1887. 

Bacillus  Tetani. — Rosenbach  describes  the  bacillus  as  an  anaerobic 
micro-organism  which  presents  a  bristly  appearance,  with  a  sjjore  at  one 
of  its  extremities  which  gives  it  the  resemblance  to  a  pin,  or  drum-stick. 

According  to  Kitasato  the  bacilli  produce  spores  in  thirty  hours  in 
cultures  kept  at  a  temperature  of  the  body.  They  possess  great  resistance 
to  heat,  as  they  have  been  found  active  after  an  exposure  of  one  hour  to 
80°  C.  of  moist  heat,  but  they  are  destroyed  by  placing  them  in  a  steril- 


FiG.  89.— Tetanus  Bacilli.    Spore-bearing  Rods  from  an  Agar  Cttlture.    Mounted 
Preparations,  Stained  with  Fuchsin.    x  1000.     (Frunkel-Ffeiffer.) 

izer  heated  to  100°  C.  for  five  minutes.  The  bacillus  has  been  found  in 
different  kinds  of  surface  soil  and  in  street-dust.  In  man  it  has  been 
found  in  tetanic  patients  in  the  wound-secretions,  in  the  nerves  leading 
from  the  seat  of  infection,  and  in  the  spinal  cord. 

Cultivation. — Rosenbach  found  it  impossible  to  obtain  a  pui-e  culture  ; 
although  he  resorted  to  fractional  cultivation,  it  was  found  that  the  last  cul- 
ture was  still  contaminated  by  one  or  more  additional  microbes.  Fluegge 
claimed  to  have  obtained  a  pure  cultivation  by  heating  for  five  minutes 
the  mixed  culture  to  100°  C,  but  after  this  procedure  the  bacillus  was 
incapable  of  further  propagation.  After  many  trials  it  was  found  that 
sterilized  solid  blood-serum  was  the  best  soil  for  the  propagation  of  the 
bacillus  outside  of  the  bod}'.     Both  Xicolaier  and   Rosenbach  observed 


BACTERIOLOGICAL    STUDIES.  '  385 

the  anaerobic  nature  of  the  bacillus,  as  it  was  found  impossible  to  obtain 
a  culture  b}^  streak  inoculations,  or  in  any  other  manner  by  which  oxygen 
could  not  be  excluded.  The  culture  appeared  slowl}',  as  a  delicate, 
whitish-gra}'  film,  in  the  track  of  the  stab  inoculation,  below  the  surface 
of  the  culture  substance.  B3'  a  long  series  of  cultures,  Rosenbach 
finallj'  succeeded  in  eliminating  all  other  microbes,  with  the  exception  of 
a  bacillus  of  putrefaction.  The  growth  of  the  bacillus  takes  place  most 
readily  at  an  equable  temperature  of  37°  C.  (98.6°  F.),  and  becomes  first 
visible  about  the  third  daj'  in  the  depth  of  the  culture  media.  Kitasato 
has  finall}'  succeeded  in  obtaining  a  pure  culture  of  the  bacillus  of 
tetanus  from  pus  taken  from  a  patient  suffering  from  this  disease.  As 
the  bacillus  will  only  grow  where  atmospheric  air  can  be  excluded,  he 
exposed  his  cultures  to  hydrogen  gas  with  complete  exclusion  of  oxygen. 
Mixed  cultures,  which  had  been  kept  for  several  da3-s  in  the  incubator, 
were  then  exposed  for  half  an  hour  to  a  temperature  of  80°  C.  Further 
growth  was  then  obtained  upon  plate  cultures  in  closed  glass  vessels 
filled  with  hj-drogen  gas.  By  heating  the  mixed  culture  to  80°  C.  he 
destroyed  all  microbes  with  the  exception  of  the  bacillus  of  tetanus, 
which,  later,  was  cultivated  upon  solid  nutrient  media  in  an  atmos- 
phere of  hydrogen  gas.  At  a  temperature  of  18°  to  20°  C,  a  visible 
culture  appeared  at  the  end  of  a  week.  If  the  temperature  was  increased 
to  blood-heat  the  bacilli  and  spores  developed  more  rapidl3\ 

Inoculation  Experiments. — Nicolaier  produced  tetanus  in  rabbits  and 
mice,  experimentall}^,  by  inoculations  with  different  kinds  of  surface  soil. 
Out  of  140  experiments,  in  69  a  disease  was  produced  identical  with 
tetanus  in  man.  In  the  pus,  at  the  point  of  inoculation,  bacilli  and 
micrococci  were  constantl}'  found.  Among  the  bacilli  one  form  was 
constantly  present;  this  bacillus  resembled  in  appearance  and  culture 
the  bacillus  of  septicaemia  in  mice,  but  was  more  slender.  This  bacillus 
was  found  in  isolated  places  in  the  connective  tissue,  but  could  not  be 
found  in  the  muscles,  nerves,  and  blood.  Earth  sterilized  by  exposing  it 
to  a  high  temperature  for  an  hour  proved  harmless,  showing  conclusively 
that  the  contagium  of  tetanus  liad  been  destroyed.  Inoculations  with 
pus  taken  from  tetanic  animals  were  most  successful.  Inoculations 
with  mixed  cultures  grown  in  solidified  blood-serum  j-ielded  positive 
results. 

Rosenbach  made  his  experiments  with  mixed  cultures  grown  from 
pus,  taken  from  the  line  of  demarcation  of  a  case  of  frost  gangrene,  in 
a  patient  who  had  died  of  tetanus.  The  inoculations  proved  successful. 
Bonone  reports  the  case  of  a  man  suffering  from  paraplegia,  the  result 
of  disease  of  the  spine  in  the  dorsal  region,  complicated  by  an  exten- 
sive sacral  decubitus,  the  seat  of  phlegmonous  inflammation,  who  was 

25 


386  PRINCIPLES   OF   SURGERY. 

suddenl}^  attacked  by  tetanus,  which  proved  fatal  in  two  days.  One  hour 
after  death  a  small  portion  of  the  infiltrated  tissue  around  the  gangre- 
nous part  was  removed,  and  after  reducing  it  to  a  fine  pulp  by  tritura- 
tion he  injected  it  under  the  skin  of  a  rabbit.  Twenty-two  hours  after 
inoculation  tlie  animal  died  with  well-marked  symptoms  of  tetanus.  The 
products  of  inflammation  from  the  point  of  injection  thrown  into  tlie 
subcutaneous  tissue  of  other  animals  produced  the  disease,  while  intra- 
venous injections  proved  harmless.  The  gravit}^  of  symptoms  following 
subcutaneous  injections  was  commensurate  with  the  quantity  of  fluid 
injected.  Guinea-pigs  proved  less  susceptible  to  infection  than  rabbits. 
In  the  pus  taken  from  the  dead  tissue  he  found,  ])esides  the  usual 
pus-microbes,  a  bacillus  which  resembled  in  every  respect  the  one  de- 
scribed by  Nicolaier  and  Rosenbach.  Hochsinger  made  his  observations 
on  a  case  of  tetanus  which  proved  fatal  on  the  fifth  day.  The  day  before 
the  patient  died  blood  was  abstracted  from  a  vein,  under  strict  antiseptic 
precautions,  for  microscopical  and  bacteriological  study.  No  micro- 
organisms could  be  found  in  it.  With  the  greatest  care  sterilized,  solid 
blood-serum  was  inoculated  with  the  blood,  by  making,  with  the  needle, 
both  superficial  streaks  and  deep  punctures.  The  nutrient  medium  was 
kept  at  a  temperature  of  37°  C.  (98.6°  F.).  On  the  third  day  a  white, 
cloud}'  streak  marked  the  direction  of  the  deep  punctures,  while  the 
superficial  plant  remained  sterile.  On  the  third  day  a  portion  of  the 
culture  was  removed  and  stained  with  aniline  gentian,  and  the  character- 
istic bacillus  was  found.  A  large  rabbit  was  infected  by  injecting  blood 
obtained  from  the  patient  during  life.  The  blood  was  diluted  with 
sterilized  water,  and  a  syringeful  of  this  mixture  was  injected  under  the 
skin  in  the  iliac  region,  and  half  of  this  quantity  under  the  skin  of  the 
left  thigh.  The  next  da}'  the  animal  was  quite  ill  and  unable  to  use  the 
left  hind-leg,  which  was  dragged  along  in  walking.  At  this  time  great 
nervous  excitability  was  observed,  the  exaggerated  reflex  symptoms 
being  especially  well  marked  in  the  posterior  extremities,  which,  on  the 
slightest  touch,  were  thrown  into  clonic  spasm.  On  the  following  day 
the  animal  was  found  dead.  A  few  hours  before  death  well-marked  symp- 
toms of  tetanus  developed.  Injections  of  blood  from  this  animal  pro- 
duced no  results  in  otlier  rabbits,  and  culture  experiments  were  equally 
fruitless.  A  syringeful  of  inspissated  blood  of  the  patient,  kept  for  three 
weeks,  thrown  under  tlie  skin  of  a  white  mouse,  was  followed  by  a  fatal 
attack  of  tetanus,  while  a  second  animal  inoculated  in  a  similar  manner 
with  one-half  of  this  quantity  remained  perfectly  well. 

Fluegge  had  before  observed  that  by  injecting  blood  from  animals 
rendered  tetanic  by  inoculation  it  was  noces^ary  to  use  a  large  quantity 
in  order  to  reproduce  the  disease  in  other  animals,  and  even  by  doing  so 


BACTERIOLOGICAL    STUDIES.  387 

the  result  was  not  alwaj^s  satisfactory.  It  appears  that  the  blood  of  tet- 
anic patients  possesses  greater  toxic  properties  than  the  blood  of  animals 
suffering  from  the  same  disease.  Hochsinger  also  made  inoculations 
with  the  mixed  cultures.  A  S3^ringeful  of  a  liquid  culture  was  injected 
into  the  subcutaneous  tissue  of  a  medium-sized  rabbit.  The  next  day 
the  reflexes  were  increased,  respiration  more  rapid,  and  the  animal 
appeared  otherwise  quite  sick.  On  the  third  day  the  posterior  extremi- 
ties were  stiff,  the  animal  dragging  them  in  walking;  reflex  irrital)ility 
enormousl^^  exaggerated.  On  the  fifth  day  the  animal  died,  with  well- 
marked  symptoms  of  tetanus.  A  number  of  similar  successful  experi- 
ments are  reported  by  the  same  autlior.  In  rabbits,  Fluegge  estimated 
the  stage  of  incubation  at  from  three  to  five  days,  and  the  duration  of 
of  the  disease,  from  the  time  the  first  S3'mptoms  were  noticed  to  tlie  fatal 
termination,  from  five  to  seven  days. 

Beumer  gives  an  accurate  and  able  description  of  his  studies  in  2 
cases  of  tetanus.  Tlie  first  case  occurred  in  a  mechanic,  who  injured 
himself  under  the  nail  of  the  right  middle  finger  with  a  splinter  of  wood. 
Eight  da3's  after  the  injur}',  tlie  patient  having  had  but  sliglit  pain  in  the 
finger,  pains  appeared  in  the  neck  and  muscles  of  the  back.  Tlie  next 
morning  spasms  of  the  muscles  of  the  chest,  abdomen,  and  jaw  developed. 
These  attacks  occurred  at  intervals  of  an  hour  and  a  half  Four  daj^s 
later  the  lower  extremities  were  affected,  also  the  upper,  but  in  a  less 
degree.  An  incision  was  made  and  the  foreign  bod}'  removed,  which 
was  followed  b}^  the  escape  of  a  drop  of  pus ;  death  on  the  fourth  day. 
The  second  case  was  a  boy  6^  years  old,  who  was  brought  into  the  clinic 
with  well-marked  symptoms  of  tetanus,  and  who  lived  only  a  few  hours 
after  his  admission.  The  author  obtained  some  of  the  dust  and  splinters 
of  wood  from  the  place  where  the  mechanic  had  injured  himself,  and  in- 
serted small  particles  under  the  skin  of  mice  and  rabbits.  In  all  experi- 
ments the  animals  were  attacked  with  tetanus  in  from  two  to  three  daj'S 
after  inoculation,  and  during  the  third  or  fourth.  The  spasms  were 
always  noticed  first  in  the  muscles  nearest  the  point  of  inoculation.  A 
fragment  of  tissue  from  the  sole  of  the  foot  was  taken  from  the  bo}^  and 
small  particles  of  it  inserted  into  the  subcutaneous  tissue  of  6  mice. 
In  all  of  these  symptoms  of  tetanus  appeared  after  two  days,  developing 
gradually  into  general  convulsions  and  death. 

The  same  results  were  obtained  in  mice  and  rabbits  b}'  inoculations 
of  particles  of  dust  taken  from  the  spot  where  the  boy  sustained  the 
injury.  The  same  author  also  made  numerous  experiments  with  different 
kinds  of  earth.  Of  10  experiments  with  soil  taken  from  the  ocean- 
beach,  tetanus  followed  in  onl}'  2.  On  the  other  hand,  of  10  inocu- 
lations with  garden-earth  and   street-dust,  all  proved  successful  but  1. 


388  PRINCIPLES   OF   SURGERY. 

Of  the  greatest  scientific  and  practical  interest  are  the  observations 
made  b^'  Bonone,  in  reference  to  the  causation  of  tetanus  by  infection 
with  earth  containing  the  bacillus  discovered  by  Nicolaier.  He  had  an 
opportunit}'  to  observe  a  number  of  cases  of  tetanus  after  the  earth- 
quake at  Bajardo.  Of  the  70  persons  injured  in  the  ruins  of  the 
church,  7  were  attacked  b}'  tetanus.  From  bacteriological  investi- 
gations in  connection  with  these  cases,  he  came  to  the  same  conclusions 
in  regard  to  the  cause  of  the  disease  as  Nicolaier,  Rosenbach,  Fluegge, 
and  Beuraer  before  him.  Of  special  importance  is  the  observation  made 
by  him,  that  the  secretions  from  the  wounds  and  the  exudation  from  the 
part,  the  seat  of  tetanic  convulsions,  when  dried  and  preserved  between 
two  sterilized  watch-glasses,  retained  tlieir  virulent  properties  for  at  least 
four  months.  All  animals  inoculated  with  dust  from  the  debris  in  the 
interior  of  the  church  were  attacked  with  tetanus.  Control  experiments 
with  dust  from  the  ruins  at  Diano-Marina  were  alwa3's  followed  by  nega- 
tive results.  Of  the  many  persons  injured  during  the  same  earthquake 
at  this  place,  not  one  Avas  attacked  by  tetanus. 

Ohlmiiller  and  Goldsclimidt  made  a  thorough  bacteriological  inves- 
tigation of  a  case  of  tetanus  following  complicated  fractui'e  of  the  right 
thumb.  The  disease  appeared  the  da^'  following  the  injury,  and  proved 
fatal  in  seventeen  hours.  Soon  after  death  inoculation  experiments  were 
made  with  blood  taken  from  the  heart  and  spleen,  and  pus  from  the  seat 
of  fracture.  The  cultures  were  grown  in  solid  blood-serum  kept  at  a 
temperature  of  38°  C,  (100.7°  F.).  The  tubes  containing  blood  from 
the  heart  and  spleen  remained  sterile,  but  the  nutrient  media  infected 
with  pus  showed  signs  of  growth.  The  bacilli  which  were  detected  re- 
sembled those  of  mouse-septicsemia,  onlj-  somewhat  larger  in  size.  In 
addition  to  these  microbes  streptococci  and  a  thick  bacillus  were  found. 
Two  mice  were  inoculated  with  this  mixed  culture.  Twelve  hours  after 
infection  tetanus  developed,  followed  b}^  death  in  seventeen  hours.  The 
spasms  commenced  in  the  tail,  extended  to  the  posterior  extremities,  and 
then  gradual]}'  advanced  in  a  forward  direction.  From  these  animals 
blood-serum  was  taken,  with  which  other  mice  were  infected.  Again, 
tetanus  was  produced,  and  successful  cultivations  were  made  of  2  mice 
of  equal  size  and  age;  1,  which  received  one  portion  of  a  culture,  died 
of  tetanus  on  the  ninth  day,  wliile  the  other,  which  received  a  dose  three 
times  as  large,  died  on  the  third  day.  Of  3  cases  of  tetanus  which 
recently  came  under  the  observation  of  Lumniczer,  he  Avas  able  to 
demonstrate  the  microbic  origin  in  1.  In  this  case  the  attack  followed 
a  gunshot  injury.  After  the  disease  had  developed  fragments  of  hemp 
were  removed  fi'om  the  canal  made  b\'  the  bullet,  and  in  them  the  char- 
acteristic bacillus  was  found.     Cultures  were  made  to  the  tenth  genera- 


BACTERIOLOGICAL    STUDIES.  389 

tion,  and  with  them  animals  were  inoculated,  and  tetanus  was  invariably' 
produced.  Pus  taken  from  abscesses  produced  at  the  point  of  inocula- 
tion contained  the  bacillus,  and  inoculation  experiments  made  with  it 
yielded  positive  results.  Cultures  made  from  the  blood  or  organs  of  the 
tetanic  animals  remained  sterile.  Inoculations  with  blood  from  these 
animals  proved  harmless. 

Kitasato  experimented  with  a  pure  culture  of  the  bacillus  of  tetanus 
on  mice,  rats,  guinea-pigs,  and  rabbits,  and  never  failed  in  producing  the 
disease,  provided  a  sufficientl}'  large  dose  of  the  culture  was  adminis- 
tered. In  mice  the  disease  appeared,  without  exception,  twenty-four 
hours  after  the  inoculation,  and  proved  fatal  in  two  to  three  daj'S.  The 
tetanic  convulsions  were  first  always  local,  appearing  first  in  the  muscles 
nearest  the  point  of  inoculation,  and  becoming  gradually'  more  diffuse. 
He  was  unable  to  find  tlie  bacillus  at  the  seat  of  inoculation,  the  blood, 
or  in  any  of  the  internal  organs.  He  is  of  the  opinion  that  if  tetanus  is 
produced  by  inoculation  with  a  pure  culture  the  bacilli  do  not  remain 
in  the  body  for  any  length  of  time,  but  are  rapidly  eliminated.  The  ex- 
periments and  clinical  observations  which  have  just  been  quoted  furnish 
conclusive  proof  that  tetanus  is  a  microbic  disease,  and  that  the  bacillus 
of  tetanus  discovered  by  Nicolaier  and  Rosenbach  is  its  essential  cause. 
Whether  cultivations  from  chronic  cases  of  tetanus  can  produce  an  acute 
and  rapidly-fatal  attack  in  animals  remains  to  be  determined.  In  this 
direction  I  have  recently'  made  an  observation  which,  if  not  convincing, 
is  at  least  very  suggestive.  A  boy  15  j-ears  of  age,  previousl}'  in  good 
health,  was  attacked  with  acute  osteomyelitis  in  the  lower  extremity  of 
the  femur.  The  surgeon  in  attendance  trephined  the  bone  just  above 
the  external  cond^-le  during  the  first  few  da3'S,and  before  an  abscess  had 
formed  in  the  soft  parts.  A  few  da3-s  after  the  operation  trismus  set  in, 
followed  by  typical  chronic  tetanus.  Six  weeks  later  the  patient  entered 
the  Milwaukee  Hospital,  and  was  placed  under  m}'  charge.  At  this  time 
the  patient  had  become  emaciated  to  a  skeleton. 

Trismus  and  opisthotonus  were  well  marked,  and  the  lower  ex- 
tremities were  rigid  and  fixed  in  the  extended  position.  The  slightest 
touch,  or  a  draught  of  air  in  the  room,  would  bring  on  intense  convul- 
sive attacks  for  several  minutes,  attended  b}'  excruciating  pain.  Pro- 
fuse fetid  discharge  at  the  site  of  operation  ;  pulse,  140  ;  temperature,  from 
99°  to  101°  F.  (37.3°  to  38.8°  C).  Believingthat  the  primary  infection 
had  taken  place  through  the  operation  wound, and  that  the  osteomjelitic 
products  served  the  purpose  of  a  nutrient  medium  for  the  bacillus  tetani, 
I  determined  to  operate  in  spite  of  the  grave  s3nnptoms.  As  the  spinal 
cord  at  this  stage  of  the  disease  was  necessaril}-  the  seat  of  the  intense 
congestion,  I  resorted  to  chloroform  as  an  anoesthetic  in  preference  to 


390  PRINCIPLES    OF    SURGERY. 

ether.  The  usual  operation  for  necrosis  of  the  lower  end  of  the  femur 
was  made,  and  a  large  triangular  sequestrum  removed  from  the  lower  and 
posterior  aspect  of  the  bone.  The  involucrum  was  defective,  and  its 
inner  surface  was  found  lined  with  a  thick  layer  of  flabb}-  granulations. 
Gelatin  tubes  were  inoculated  with  blood,  pus,  and  granulation  tissue. 
The  tube  inoculated  with  blood  remained  sterile,  while  the  two  remaining 
tubes  showed  a  copious  growth  of  staphylococcus  pyogenes  albus,  which 
rapidly  liquefied  the  gelatin.  A  portion  of  the  granulation  tissue  was 
disinfected  with  a  weak  solution  of  carbolic  acid,  dried  between  layers 
of  antiseptic  gauze,  and  inserted  under  the  skin  of  a  full-grown,  large 
rabbit.  No  suppuration  followed,  and  the  animal  remained  perfectly 
well  for  six  weeks,  when  both  posterior  extremities  became  rigid  and 
could  not  be  used  in  walking.  The  next  day  tetanic  convulsions  aflfect- 
ing  the  muscles  of  the  back  and  all  the  limbs  appeared,  and  on  the  fourth 
day  death  supervened. 

The  interesting  features  in  this  case  are  that  the  patient  recovered 
from  the  tetanus  after  a  long  illness,  extending  over  three  months  ;  that 
marked  improvement  followed  the  operation,  which  had  for  its  object 
thorough  disinfection  of  the  infection-atrium;  and  that  the  inoculation 
with  granulation  tissue  in  the  rabbit  was  followed  by  an  acute  attack  of 
tetanus  after  an  incubation  stage  extending  over  six  weeks.  In  the  ex- 
periments related  above  the  animals  were  inoculated  with  cultures,  earth, 
other  infected  foreign  substances,  fi-agments  of  diseased  tissue,  or  with 
wound-secretions  from  tetanic  patients ;  the  stage  of  incubation  rarely 
extended  over  two  or  three  days,  and  often  the  spasms  appeared  in 
eighteen  to  twenty-four  hours,  and  the  disease  produced  death  in  from 
two  hours  to  three  days. 

The  same  question  has  been  raised  in  connection  with  the  pathogenic 
action  of  the  bacillus  of  tetanus  as  with  pus-microbes:  Is  the  disease 
of  which  it  is  the  specific  cause  due  to  the  presence  of  the  microbe,  or 
the  ptomaines  which  it  elaborates  in  the  tissues  ? 

Ptomaines  of  the  Bacillus  Tetani. — Brieger,  by  his  indefatigable 
labors,  has  demonstrated  beyond  all  doubt  that  the  ptomaines  of  the 
bacillus  of  tetanus  cause  tetanic  convulsions.  Str3'chnia  in  toxic  doses 
produces  a  condition  which,  so  far  as  the  muscular  spasms  are  concerned, 
closely  resembles  tetanus.  If  this  and  other  drugs  belonging  to  the  same 
group  can  act  upon  the  si)inal  cord  in  such  a  manner  as  to  cause  spasms 
and  muscular  rigidity,  we  should,  a  priori,  expect  that  if  the  microbe 
of  tetanus  produce  ptomaines  in  the  tissues  these  might  produce  the 
same  eflTect  on  the  cord,  and  that  the  symptoms  are  produced  by  them 
and  not  b}^  the  direct  action  of  the  microbe.  Nearly  all  authorities 
are  agreed  that  the  bacilli  present  in  the  blood  of  tetanic  patients  are 


BACTERIOLOGICAL    STUDIES.  391 

few,  and  iu  animals  in  which  the  disease  was  produced  artificially  the 
blood  was  often  found  sterile.  More  microbes  have  been  found  at  the 
seat  of  primary  infection,  and  in  the  tissues  between  it  and  the  spinal 
cord,  than  in  the  blood  itself, — another  proof  that  the  direct  cause  of  the 
disease  is  the  product  of  the  microbes,  and  not  the  microbes  themselves. 
Brieger  has  succeeded  in  isolating  four  toxic  substances  from  mixed 
cultures  of  the  tetanus  bacillus  in  sterilized  emulsion  of  meat.  The 
first,  tetania,  in  doses  of  a  few  milligrammes,  administered  subcutaneously 
in  mice,  produced  the  characteristic  symptoms  of  tetanus.  The  second, 
tetanotoxin,  causes,  first,  tremors;  later,  paral^'sis  and  convulsions.  The 
third,  muriate  of  toxin,  has  not  been  designated  by  a  special  name  ;  it 
produces  also  well-marked  symptoms  of  tetanus,  but,  besides,  excites  the 
salivary  and  lachrymal  glands  to  increased  functional  activity*.  The 
last,  sjMsnwtoxin,  produces  severe  clonic  and  tonic  spasms,  which 
prostrate  the  animal  at  once.  Besides  meat-emulsion,  the  contused 
brain-substance  from  horses  and  cattle  was  used  ;  also  cows'  milk  mixed 
with  carbonate  of  lime.  It  seems  that  the  culture  substance  determined, 
to  a  certain  extent,  tlie  kind  of  toxin  which  was  produced  ;  thus,  in 
cultures  grown  in  brain-substance,  besides  the  tetanin,  tetanotoxin  was 
found  in  greatest  abundance ;  old  cultures,  in  which  the  tetanus  bacilli 
were  dead,  produced  none  of  these  toxic  substances. 

The  same  author  has  very  recently  been  successful  in  isolating 
tetanin  from  the  amputated  arm  of  a  patient  the  subject  of  tetanus. 
The  disease  had  developed  a  few  days  after  a  severe  crushing  injury  of 
the  hand  and  forearm.  The  first  symptoms  manifested  themselves  in  the 
morning,  and  at  12  o'clock  (noon)  the  operation  was  performed  ;  at 
5  o'clock  on  the  same  day  the  patient  expired  suddenlj^  during  one 
of  the  tetanic  convulsions.  The  bacilli  of  tetanus  were  found  in  the 
serum  taken  from  the  oedematous  portion  of  the  forearm,  in  connection 
with  other  bacilli  of  different  length, — staphylococci  and  streptococci. 
Serum  containing  these  microbes  injected  under  the  skin  of  mice, 
guinea-pigs,  and  rabbits  invariably  produced  tetanus.  On  the  other 
hand,  a  dog  treated  in  the  same  manner,  as  well  as  after  injections  of 
tetanin,  remained  well.  A  horse  inoculated  with  a  culture  of  bacilli  in 
meat-emulsion  showed  no  symptoms  of  tetanus,  but  an  abscess  formed 
at  the  point  of  inoculation.  The  infiltrated  tissues  of  the  amputated 
arm  planted  on  sterilized  meat-emulsion,  solid  blood-serum,  and  emulsion 
made  of  the  flesh  of  fish,  yielded,  besides  ammonia,  only  tetanin;  no 
trace  of  tetanotoxin,  spasmotoxin,  nor  the  unnamed  toxin  which  could 
be  obtained  from  Rosenbach's  bacillus.  A  moderate  dose  of  tetanin 
injected  into  the  subcutaneous  tissue  of  a  horse  produced  muscular 
contractions  which   lasted   for  a  considerable  length  of  time,  but  the 


392  PRINCIPLES   OF    SURGERY. 

characteristic  S3"mptoms  of  tetanus,  as   witnessed    in    horses    suffering 
from  tetanus,  did  not  appear. 

ETIOLOGY. 

The  clinical  and  experimental  researches  just  quoted  demonstrate 
that  the  bacillus  tetani  is  found  in  the  wound-secretions,  the  tissues, 
and,  in  some  instances,  in  the  blood  of  tetanic  patients,  and  that  tetanus 
in  animals  can  be  produced  artificial!}^  bj'  injections  of  wound-secretions 
of  tetanic  patients,  or  by  using  mixed  or  pure  cultures, — facts  which 
have  firmly  established  tlie  microbic  nature  of  the  disease.  The  essen- 
tial cause  of  tetanus  is  the  bacillus  first  discovered  b}'  Nicolaier  in 
earth,  and  by  Rosenbach  in  the  wound-secretion  of  a  tetanic  patient. 

Period  of  Incubation. — The  period  of  incubation,  both  in  man  and 
animals,  appears  to  be  extremely  variable,  in  some  instances  lasting 
only  twent3'-four  hours,  while  in  otliers  weeks  ma}'  elapse  between  the 
time  of  infection  and  the  first  manifestations  of  the  disease.  This  may 
depend  on  one  of  three  things:  1.  The  number  of  bacilli  introduced  may 
be  so  small  that  a  much  longer  time  is  necessar}'  before  active  S3'mptoms 
are  produced  than  if  a  larger  quantit}'  had  been  introduced,  as  Watson- 
Cheyne  has  shown  that  in  animals  the  injection  of  a  limited  number  of 
the  bacilli  of  tetanus  produced  no  sj'mptoms.  2.  The  location  of  the 
infection-atrium  and  anatomical  cliaracteristics  of  the  tissues  surround- 
ing it  ma}-  influence  the  time  which  is  necessary  to  develop  the  disease. 
3.  Brieger's  investigations  have  shown  that  tetanic  convulsions  in 
animals  are  produced  by  injections  of  tetanin, — one  of  the  toxic 
ptomaines  derived  from  cultures  of  the  bacillus  of  tetanus  ;  and  it  is 
more  than  probable  that  the  active  S3'mptoms  of  tetanus  in  man  are  due 
not  to  the  presence  in  the  tissues  of  tlie  bacillus,  but  to  the  toxic  action 
of  the  ptomaines  on  the  spinal  cord;  so  that  the  duration  of  the  period 
of  incubation  is  further  modified  b}^  the  capacity'  of  the  infected  tissues 
to  yield  the  different  ptomaines.  The  degree  of  virulence  of  the  bacillus 
of  tetanus  must  certainly  play  an  important  part,  not  onl}-  in  determining 
the  duration  of  the  incubation  stage,  but  also  the  gravity  of  the  disease. 

Specific  Microbic  Cause. — There  can  be  no  doubt  that  both  the 
acute  and  chronic  forms  of  tetanus  are  caused  by  the  same  microbe,  and 
that  the  clinical  difference  depends  upon  the  degree  of  virulence  of  the 
primar}'  cause,  on  the  one  hand,  and  the  degree  of  susceptibilit}'  of  the 
individuals  to  tetanic  infection,  on  the  other. 

In  reference  to  the  susceptibility  to  infection  with  the  bacillus  of 
tetanus,  it  has  been  shown  b}^  reliable  statistics  that  the  colored  races, 
under  the  same  conditions,  are  attacked  more  frequently  b}'  tetanus  than 
the  Caucasians.     Inoculation  experiments  have  shown  that  the  greatest 


ETIOLOGY.  393 

difference  exists  among  different  kinds  of  animals  in  tliis  respect,  and 
there  is  no  reason  whiy  tiie  same  difference  of  susceptibility  to  this  dis- 
ease should  not  exist  in  the  human  species.  As  the  natural  habitat  of 
the  bacillus  of  tetanus  is  the  soil,  we  can  readily  understand  that  the 
disease  should  occur  more  frequentl}'  in  some  localities  than  in  others, 
and  why  it  is  more  prevalent  in  southern  than  northern  climates.  The 
excretions  and  cadavers  of  tetanic  animals  may  infect  the  soil,  where, 
under  favorable  conditions,  the  bacillus  may  multiply,  and  in  this  manner 
a  greater  or  less  portion  of  the  surface  soil  becomes  a  nutrient  medium, 
in  which  an  immense  culture  is  developed  from  which  new  cases  can 
become  infected.  A  Avarm  climate  is  more  favorable  for  the  unlimited 
reproduction  of  the  bacillus  in  the  soil  tlian  northern  countries  ;  hence 
the  greater  prevalence  of  this  disease  in  the  tropics. 

Infection -Atrium. — As  the  bacillus  of  tetanus  is  the  essential 
cause  of  the  disease,  the  remaining  causes  are  accidental  conditions, 
which  result  in  the  formation  of  an  infection-atrium.  We  have  no  evi- 
dence that  the  bacillus  can  enter  the  tissues  through  an  intact  mucous 
membrane  or  unbroken  skin.  Idiopathic  tetanus,  so  called,  is  a  clinical 
form  of  tetanus  where  even  the  most  thorough  examination  reveals  no 
infection-atrium.  As  in  cases  of  erysipelas,  under  similar  circumstances, 
the  local  lesion  may  have  been  so  insignificant  as  not  to  have  attracted 
the  patient's  attention,  or  if  he  was  cognizant  of  it  at  the  time  it  maj- 
have  completely  disappeared  at  the  time  the  first  symptoms  developed 
themselves. 

In  t7'ismiis  sive  tetanus  neonatorum  infection  undoubtedly  takes 
place  through  the  umbilicus.  In  a  case  of  this  kind  Beumer  found  the 
tetanus  bacillus  in  the  tissues.  There  is  hardly  an  operation,  capital 
and  minor,  which  has  not  furnished  its  quota  to  the  long  list  of  tetanic 
patients.  It  has  been  observed  most  frequentl}'  after  amputation,  castra- 
tion, and  extirpation  of  the  th3'roid  gland. 

Weiss  reported  13  cases  of  tetanus  occurring  after  extirpation  of 
the  thyroid  gland.  He  attributes  the  frequency  with  which  this  disease 
follows  the  removal  of  this  organ  to  irritation  of  peripheral  nerves 
induced  b}-  the  numerous  ligatures.  Middeldorpf  observed  paralj-sis  of 
the  facial  nerve  in  some  of  these  cases, — a  circumstance  which  would 
indicate  a  central  origin  of  the  disease.  lu  53  total  extirpations  of  the 
thyroid  gland  for  goitre  made  by  Billroth,  tetanus  followed  in  12  cases, 
while  no  cases  occurred  in  109  partial  operations.  Two  cases  became 
chronic,  in  Avhich  the  disease,  at  the  time  von  Eiselsbei'g  made  the  report, 
had  lasted  for  six  and  nine  j^ears.  In  7  cases  there  was,  besides  the 
ordinar}-  characteristic  symptoms,  an  involvement  of  the  muscles  of  the 
face,  neck,  larynx,  diaphragm,  and  abdomen  ;  so  that  dyspnoea  and  even 


39  i  PRINCIPLES   OF   SURGERY. 

loss  of  consciousness  occurred.     In   the   fatal  cases  death  occurred  in 
from  three  to  thirt}'  da3's,  and  in  1  case  after  seven  months. 

Quite  a  number  of  cases  have  been  reported  during  tlie  last  few 
years  where  it  occurred  after  abdominal  section.  Tetanus  occurring 
after  an  operation  must  be  the  result  of  infection  through  the  operation 
wound  with  the  specific  bacillus,  which,  without  exception,  takes  place 
by  contact.  As  the  bacillus  of  tetanus  is  not  a  pyogenic  microbe,  it  is 
not  necessarj'  that  a  wound  through  which  infection  has  occurred  should 
suppurate.  When  suppuration  takes  place  it  is  in  consequence  of  a 
mixed  infection.  It  is  a  well-known  clinical  fact  that  punctured,  lacer- 
ated, and  gunsliot  wounds  of  the  hands  and  feet  are  most  liable  to  be 
followed  by  tetanus.  Before  it  was  known  that  tetanus  is  a  microbic 
disease,  the  frequency  with  which  this  disease  complicated  such  injuries 
was  explained  upon  the  ground  that  the  part  injured  was  abundantly 
supplied  with  sensitive  nerves,  and  that  the  irritation  caused  by  the 
injury  provoked  the  disease.  As  thousands  of  operations  upon  the 
hands  and  feet  performed  under  antiseptic  precautions  have  not  resulted 
in  a  single  instance  in  tetanus,  this  ex[)lanation  is  no  longer  tenable. 
The  antiseptic  treatment  of  wounds  has  greatly  diminished  the  fre- 
quency of  tetanus  as  a  complication  of  operation  wounds.  Expe- 
rience has  shown  that  the  same  treatment  wliich  prevents  suppuration 
and  other  wound-infetitive  diseases  has  also  diminished  the  frequency 
of  tetanus.  Wounds  of  the  hands  and  feet  are  so  often  followed  by 
tetanus,  because,  in  the  first  place,  the  implement  or  substance  which 
inflicts  the  wound  is  frequently  contaminated  with  infected  earth  or 
dust,  and,  in  the  second  place,  such  wounds  are  often  neglected  ami 
exposed  to  subsequent  infection  from  the  same  sources;  and,  lastl}', 
infected  foreign  bodies  are  often  allowed  to  remain  in  the  wound.  In 
a  number  of  instances  animals  were  successfully  infected  by  inserting 
under  the  skiii  particles  of  foreign  bodies  removed  from  tetanic  patients. 
Wounds  of  the  hands  and  feet  are  no  more  liable  to  cause  tetanus  than 
wounds  in  any  other  jjart  of  the  body,  provided  they  are  not  exposed  to 
greater  7'isk  of  infection.  Infection  through  the  uterus  after  abortion 
and  during  childbed  has  been  repeatedly  observed. 

Gautier  has  collected  74  cases  of  tetanus,  36  following  abortion  and 
38  following  confinement.  Autopsies  were  made  in  15  cases  ;  3  pre- 
sented, on  microscopical  examination  of  the  brain  and  cord,  no  appreci- 
able lesion  ;  in  1  case  a  retained  putrefied  })lacenta  was  found  in  the 
uterus ;  in  5  suppurative  metritis  or  salpingitis ;  in  1  ovarian  cyst. 
The  other  autopsies  showed  hj^perffimia  of  brain,  cord,  and  meningitis; 
in  1  haemorrhage  into  the  lateral  ventricles.  Ten  patients  recovered, — 5 
after  abortion,  5  after  labor. 


SYMPTOMS   AND    DIAGNOSIS.  395 

Frost  gangrene  is  especially  prone  to  be  followed  b}'  tetanus.  Of 
3T5  cases  of  tetanus  collected  by  Thamha^^n,  the  disease  followed  wounds 
of  the  fingers  and  hand  in  27  per  cent,;  of  the  thigh  and  leg,  25  per  cent.; 
of  the  toes  and  foot,  22  per  cent.;  of  the  head,  face,  and  neck,  11  per  cent.; 
of  the  arm  and  forearm,  8  per  cent.;  and  of  the  trunk,  6  per  cent.  Of  TOO 
cases  collected  b}'  the  same  author,  the  disease  was  known  to  have  fol- 
lowed a  trauma  in  603.  As  males  are  more  frequently  exposed  to  injury 
than  females,  the  disease  is  correspondingly  more  frequent  in  that  sex. 
The  largest  number  of  tetanic  patients  are  found  among  persons  from 
10  to  30  years  of  age,  although  no  age  is  entirely  exempt.  According 
to  Larre}',  Cullen,  and  Dupu^-tren,  the  disease  can  be  caused,  and  is 
always  aggravated,  by  drafts  of  cold  air.  That  the  disease  is  never 
caused  b^-  exposure  to  cold  requires  no  argument ;  that  drafts  of  cold 
air  aggravate  the  disease  when  it  exists  is  unquestionable,  as  every 
peripheral  irritation  cannot  fail  in  aggravating  the  muscular  spasms. 

SYMPTOMS   AND    DIAGNOSIS. 

The  ptomaines  of  the  bacillus  of  tetanus  act  upon  the  brain  and 
spinal  cord  in  a  somewhat  similar  manner  as  strychnia.  If  the  spinal 
cord  is  injured  str3'chnia  acts  only  upon  the  parts  supplied  with  nerves 
from  the  intact  portion  of  the  cord.  If  the  posterior  roots  of  the  spinal 
nerves  are  divided  it  produces  no  spasms  in  toxic  doses.  If  in  an  animal 
the  brain  and  medulla  oblongata  are  removed  the  effect  of  str3'chnia  upon 
the  muscles  is  not  impaired.  Injection  of  hydrate  of  chloral  arrests  the 
spasm  produced  bj'  strychnia,  and,  consequently,  chloral  must  be  con- 
sidered as  the  most  efficient  antidote  to  strychnia.  Even  the  most  acute 
cases  of  tetanus  begin  insidiously.  The  patient,  perhaps,  complains  of  a 
sensation  of  chilliness  and  a  feeling  of  soreness  about  the  region  of  the 
neck,  and  shooting  pains  and  stiffiiess  in  particular  muscular  groups. 
The  first  symptom  which  announces  the  onset  of  this  dreadful  disease 
is  difficulty  in  mastication.  The  patient  discovers,  accidentall}-,  that  he 
is  unable  to  open  the  mouth  sufficiently  to  drink  or  grasp  the  food.  On 
inspection  nothing  abnormal  is  found,  but  on  trying  to  separate  the 
teeth  the  masseter  muscle  on  each  side  becomes  rigid  and  prominent. 
This  spasm  of  the  muscles  of  mastication  is  called  trismus.  It  is  the 
first  group  of  muscles  affected  by  the  central  lesion  produced  bj^  the 
ptomaines  of  the  tetanus  bacillus.  If  other  causes  of  this  condition,  such 
as  inflammator3-  lesions  in  the  phar3'nx  and  the  alveoli  of  the  maxillar3' 
boneo,  can  be  excluded,  the  existence  of  trismus  is  almost  a  pathogno- 
monic symptom  of  tetanus.  The  patient  next  complains  of  difflcult3'  in 
swallowing,  as  the  muscles  of  deglutition  become  affected.  The  next 
muscular  groups  to  become  involved  are  the  muscles  back  of  the  neck 


396  PRINCIPLES   OF    SURGERY. 

and  the  extensors  of  the  spine,  giving  rise  to  retraction  and  fixation  of 
the  head  and  overextension  of  the  spine, — conditions  which,  when  well 
developed,  produce  what  is  called  opisthotonus.  In  well-marked  opis- 
thotonus the  bod}'  rests  on  the  occiput  and  heels  when  the  patient  is  in 
the  dorsal  position.  If  the  bod\'  is  bent  in  an  opposite  direction,  from 
contraction  and  rigidity  of  the  anterior  pectoral  aud  abdominal  muscles, 
the  condition  is  called  emjjrosthotomis.  Contraction  of  muscles  on  the 
side  of  the  chest  and  abdomen  gives  rise  to  X)leurosthotomis.  Orthotonus 
means  tonic  spasm  and  rigidity  of  all  the  voluntary  muscles, — a  con- 
dition frequentl}'  present  in  advanced  cases  of  tetanus.  The  face  of 
tetanic  patients  presents  a  characteristic  mask-like  appearance  from  the 
contraction  and  rigidity  of  the  facial  muscles.  The  muscular  spasms  are 
clonic,  and  are  always  aggravated  b}^  the  slightest  causes,  as  walking  in 
the  room  ;  touching  the  bed-clothes  or  the  body  of  the  patient ;  drafts  of 
air  ;  sudden,  unexpected  noises.  The  affected  muscles  are  rigid  from 
tonic  contraction,  but  this  state  of  rigidity  is  increased  by  the  parox3^smal 
clonic  spasms. 

In  acute  cases  the  temperature  soon  rises  to  40^  to  41°  C,  and  the 
pulse  is  correspondingly  increased  in  frequency.  The  temperature  curve 
shows  but  little  change  during  twenty-four  hours.  The  sensorium  usu- 
ally  remains  unaffected  throughout  the  entire  course  of  the  disease.  As 
the  patient  finds  it  difficult  to  clear  the  mouth,  the  profuse  salivar}^  se- 
cretion escapes  from  the  mouth.  Respiration  is  impeded  in  proportion 
to  the  number  of  the  respirator}^  muscles  affected.  In  severe  cases  early 
dyspnoea  and  cyanosis  are  present.  Special  senses  remain  intact.  The 
pain  is  mostly  excruciating,  extending  from  the  necli  and  back  in  the 
direction  of  the  nerves,  leading  to  the  affected  muscular  groups.  The 
pain  is  always  aggravated  with  the  increased  convulsive  movements, 
resulting  from  the  action  of  exteimal  irritants. 

In  consequence  of  deficient  food-suppl}^  the  intense  pain,  and  loss 
of  sleep,  rapid  emaciation  and  loss  of  strength  appear  as  early  and  con- 
stant symptoms.  Approaching  exhaustion  is  announced  b}'  profuse 
clamm}^  perspiration,  coldness  of  the  extremities,  and  a  rapid,  feeble,  and 
intermittent  pulse.  As  soon  as  the  intercostal  muscles  are  affected  res- 
piration becomes  more  and  more  embarrassed,  and  when  finally  the 
diaphragm  is  thrown  into  a  tonic  spasm  respirations  and  pulse  cease, 
general  cyanosis  follows,  and  death  may  ensue  during  the  first  spasm  of 
the  diaphragm.  Should,  however,  the  patient  rail}'  from  this  attack,  he 
will  be  almost  certain  to  succumb  to  the  second  or  third  attack. 

Wunderlich  has  seen  the  temperature  shortly  before  death  risf  to 
42°  or  43°  C,  and  the  same  has  been  observed  in  animals  dying  from 
tetanus  by  Billroth,  Fick,  and  Ley  den.     A  post-mortem  rise  in  tempera- 


CLINICAL   FORMS   OF    TETANUS.  397 

ture  to  44.7°  C.  has  been  recorded  b}'  "Wunderlich,  and  he  attributed  this 
strange  phenomenon  to  paralj'sis  of  the  central  heat-moderators.  In 
chronic  tetanus  the  disease  commences  very  insidiously,  and  the  gi'aver 
symptoms,  such  as  a  ver}'  high  temperature,  feeble  and  intermittent  pulse, 
spasm  of  the  intercostal  muscle  and  diaphragm,  are  absent.  The  tem- 
perature is  normal  or  onl}'  slightly-  elevated.  Trismus  is  alwaj'S  present, 
to  which  may  be  added  spasm  and  rigiditj^  of  the  muscles  of  the  back 
.  of  the  neck  and  the  extensors  of  the  spine.  The  trismus  makes  it  diffi- 
cult to  administer  food  in  sufficient  quantity,  and,  on  this  account,  pro- 
gressive emaciation  is  one  of  the  prominent  features  of  this  form  of 
tetanus,  as  the  disease,  as  a  rule,  lasts  from  six  to  ten  weeks.  The  dis- 
appearance of  S3'mptoms  is  as  gradual  as  their  onset.  In  the  differential 
diagnosis  it  is  important  to  distinguish  between  tetanus  and  strychnia 
poisoning,  hj-steria,  cataleps}',  hj'drophobi'a,  cerebro-spinal  meningitis, 
and  basilar  meningitis.  With  few  exceptions  it  is  possible  in  tetanus  to 
establish  the  fact  of  infection,  and  the  clinical  history  shows  that  differ- 
ent muscular  groups  become  involved  successively  in  regular  order,  first 
trismus,  then  rigidit}'  of  the  muscles  at  the  back  of  the  neck,  and,  finally, 
opisthotonus.  In  acute  cases  the  disease  is  attended  b}-  a  continuously 
high  temperature.  In  strychnia  poisoning  the  maximum  sj-mptoms, 
opisthotonus  or  orthotonus,  are  developed  suddenly,  as  soon  as  a  toxic 
dose  of  the  drug  has  been  absorbed.  The  convulsive  movements  in 
h3'steria  are  not  limited  to  an}'  definite  muscular  groups,  and  the  pulse 
and  temperature  are  normal.  The  same  can  be  said  of  cataleps3\  In 
hj'drophobia,  as  we  shall  see  subsequently,  the  spasms  are  limited  to  the 
muscles  of  deglutition,  the  stage  of  incubation  is  longer  than  in  tetanus, 
and  infection  is  always  caused  by  the  bite  of  a  rabid  animal,  usually  a  dog. 
In  cerebro-spinal  meningitis  muscular  spasm  and  rigidit}'  are  limited  to 
the  extensor  muscles  of  the  spine  ;  so  that,  even  if  the  disease  has  caused 
well-marked  opisthotonus,  trismus  is  absent.  Tubercular  meningitis  is 
usually  ushered  in  by  intense  headache,  vomiting,  and  photophobia,  and 
if  tonic  muscular  spasms  set  in  thej-  affect  the  muscles  at  the  back  of  the 
neck  almost  exclusively.     Trismus  is  never  present. 

CLINICAL   FORMS   OF   TETANUS. 

Acute  Tetanus. — The  stage  of  incubation,  as  a  rule,  is  shorter  than 
is  the  chronic  form  of  the  disease.  Trismus  develops  graduall}^  but 
after  it  has  once  been  established  the  extension  of  the  disease  to  other 
muscular  groups  is  rapid.  A  high  temperature  and  rapid,  feeble  pulse 
are  always  present.  Respiration  is  mechanically  embarrassed  b}'  the 
successive  implication  of  the  diflTerent  muscular  groups  which  are  con- 
cerned in  the   function  of  respiration,  the  last  one  to  become  affected 


398  PRINCIPLES   OF    SURGERY. 

being  the  diaphragm.  The  disease  may  prove  fatal  in  twentj'-fonr  hours, 
and  the  duration  is  seklom  prolonged  for  more  than  a  week. 

Chronic  Tetanus. — The  disease  not  only  commences  insidiously,  but 
the  symptoms  appear  gradually  and  never  develop  to  the  same  extent  as 
in  acute  tetanus.  Tliemo.st  marked  feature  is  trismus,  which  may  be  fol- 
lowed by  a  mild  degree  of  opisthotonus.  The  muscles  of  respiration  are 
not  implicated,  and  if  death  result  it  is  from  marasmus  and  exhaustion 
and  not  from  apna>a.  The  duration  of  the  disease  is  seldom  less  than 
six,  nor  more  tlian  ten,  weeks. 

Trismus. — Tetanus  in  which  only  the  muscles  of  mastication  are 
affected  is  called  trismus.  With  the  exception  of  the  infantile  form, 
trismus  is  a  chronic  and  comparatively  benign  affection. 

Tetanus  Neonatorum. — Tetanus  occurring  in  infants  during  the  first 
week  after  birth  is  clinically  characterized  as  trismus,  and  proves  fatal 
almost  without  exception  in  a  few  days.  Infection  takes  place  through 
the  umbilicus  before  or  after  separation  of  the  cord.  It  is  a  disease 
that  occurs  much  more  frequently  in  tropical  than  northern  climates, 
for  reasons  which  hnvo  been  heretofore  explained. 

Tetanus  Hydrophobicus,  or  Head  Tetanus. — This  is  a  form  of  tetanus 
which  was  first  described  by  E.  Rose,  in  1870.  In  the  cases  which  have 
been  reported,  it  followed  liead  injuries,  especiall3'  wounds  of  the  face. 
Besides  trismus,  it  is  characterized  by  paralysis  of  the  facial  nerve  on 
the  injured  side.  During  deglutition,  the  muscles  which  are  concerned 
in  this  act  are  thrown  into  spasm,  and  on  this  account  the  disease  bears 
a  strong  resemblance  to  hydrophobia.  Klemm  has  collected  up  to  date 
24  reported  cases  of  this  disease.  Most  of  them  i-ecovered,  and  in  those 
that  died  the  disease  passed  into  the  typhoid  form  of  tetanus. 

PROGNOSIS. 
The  most  important  element  in  prognosis  is  the  type  of  the  disease. 
The  more  acute  the  onset  and  the  more  intense  the  symptoms,  the  greater 
the  immediate  danger  to  life.  If  death  does  not  occur  within  two  weeks 
the  prospects  of  an  ultimate  recovery  are  good.  Of  280  cases  which 
comprise  the  Calcutta  statistics  of  this  disease  75  per  cent,  proved  fatal. 
This  list  represents  about  the  average  mortalit}^  of  this  disease.  The 
greater  the  excitability  of  the  motor  centres  of  the  spinal  cord,  and  the 
more  rapid  the  successive  involvement  of  different  muscular  groups,  the 
greater  the  danger  of  an  early  dissolution.  In  acute  cases  death  is 
alwa3's  preceded  b}^  great  dyspnoea,  and  death  usually  occurs  during  an 
attack  of  convulsions,  in  which  the  intercostal  muscles  and  the  diaphragm 
take  part.  Chronic  cases  terminate,  as  a  rule,  in  recovery  after  an 
illness  lasting  from  six  to  ten  weeks. 


PATHOLOGY    AND    MORBID    ANATOMY.  399 

PATHOLOGY    AND    MORBID    ANATOMY. 

The  absence  of  gross  pathological  changes  is  characteristic  of 
tetanus.  The  only  constant  lesion  found  is  a  h^^persemic  condition  of 
the  medulla  oblongata  and  the  spinal  cord,  to  which  special  attention  has 
been  called  b}'  Leyden,  Joffrey,  Ilunvier,  and  Robin.  As  all  of  the 
peripheral  manifestations  of  tlie  central  lesion  point  to  an  increased 
excitability  of  the  nervous  centre,  we  would  expect  that  the  principal 
lesions  are  to  be  found  in  the  gra^'  substance  of  the  cord.  In  1857 
Rokitansky  described  tetanus  as  an  ascending  neuritis.  He  found  a 
connective-tissue  proliferation,  in  the  form  of  a  semi-fluid,  adhesive, 
gra3-ish  substance,  between  the  medullary  elements  of  the  nerves  leading 
from  the  infected  district.  In  some  cases  he  found  extensive  destruction 
of  the  nerve-tubes,  and  their  space  occupied  by  the  products  of  granular 
degeneration, — colloid  and  amyloid  corpuscles. 

Lockhart-Clark  and  Dickinson  found,  as  the  most  constant  patho- 
logical lesion,  inflammatory  softening  of  the  gray  substance  of  the  cord 
and  dilatation  of  the  vessels.  Michaud  and  Benedict  found  cell  prolifera- 
tion into  the  anterior  cornua  of  the  cord  and  great  vascularit}'.  Elischer 
i-egarded  the  central  lesion  as  a  myelitis  with  vacuolation  in  the  ganglia- 
cells.  Tyson  found  in  2  cases  destruction  of  the  central  canal  of  the 
cord,  with  disintegration  of  the  posterior  cornua.  Aufrecht  narrowed 
the  morbid  anatomy  of  tetanus  down  to  atrophy'  of  the  anterior  horns, 
in  the  cervical  portion  of  the  spinal  cord.  Schultze  was  never  able  to 
discover  any  evidences  of  myelitis.  The  hyperemia  of  the  cord,  which 
is  so  constantly  found,  may  be  the  result  of  a  passive  congestion;  at 
present  this  cannot  be  accepted  as  proof  of  inflammation,  because  in 
most  cases  the  anatomical  and  clinical  evidences  do  not  sustain  this 
supposition.  The  view  that  tetanus  is  essentiall}'  an  ascending  neuritis, 
as  was  claimed  by  Rokitansk}^,  is  no  longer  tenable,  since  it  is  not 
supported  by  the  results  of  recent  investigations.  It  is  left  for  future 
research  to  furnish  more  reliable  information  concerning  the  pathology 
and  morbid  anatomy  of  tetanus.  At  present  we  can  onl}-  surmise  that 
the  ptomaines  of  the  bacillus  act  upon  the  gray  matter  of  the  cord,  where 
minute  lesions  are  produced,  w^hich  must  account  for  the  clinical  mani- 
festations of  the  disease. 

TREATMENT. 

The  prophylactic  treatment  of  tetanus  has  in  view  the  prevention  of 
infection  by  the  usual  antiseptic  precautions  in  the  treatment  of  wounds 
and  local  lesions  which  might  become  the  necessar}-  infection-atrium. 
As  tetanus  follows  more  frequently  injui'ies  insignificant  in  tliemselves 
than  large  wounds  or  major  operations,  it  behooves  the  surgeon  to  treat 
the  minutest  lesions  with  the  greatest  care,  and  in  strict  accordance  with 


400  PRINCIPLES   OF    SURGERY. 

antiseptic  principles.  Foreign  bodies  slioiild  be  carefull}^  searched  for 
and  removed.  Even  the  most  recent  accidental  wounds  should  l)e  treated 
as  infected  wounds,  and  should  be  rendered  aseptic  by  a  thorough 
primar3'  disinfection.  The  antiseptic  treatment  must  be  continued  until 
the  wound  is  completel3Miealed,  and  during  this  time  the  injured  part 
must  be  kept  at  rest.  Wounds  of  the  lower  extremities  must  be  treated 
by  confining  the  patient  to  bed,  and  wounds  of  tlie  upper  extremities 
demand,  in  their  treatment,  fixation  of  the  limb  upon  some  kind  of  a 
splint  or,  at  least,  suspension  in  a  sling. 

In  acute  cases  of  tetanus  the  most  that  can  be  expected  from  treat- 
ment is  palliation.  The  excruciating  pain  is  often  only  relieved  by 
inhalation  of  chloroform.  The  administration  of  chloroform  should  be 
conducted  by  the  phj'sician  in  attendance  or  .a  reliable  assistant,  and 
should  only  be  carried  to  the  extent  of  relaxing  the  contracted  muscles, 
and  repeated  as  often  tvs  necessary  to  procure  rest.  Morphia  in  doses 
of  4  to  ^  grain,  with  ^^^  grain  of  atropia,  should  be  given  hypodermati- 
cally  every  three  or  four  hours  until  the  desired  effect  is  reached.  In 
less  severe  cases  the  internal  use  of  hydrate  of  chloral  and  potassic 
bromide,  each  in  doses  of  from  15  to  20  grains,  can  be  given  every  three 
or  four  hours  with  excellent  effect.  Woorara,  which  has  been  quite 
extensively  used  in  the  treatment  of  the  disease,  is  absolutely  contra- 
indicated,  as  its  paralytic  effect  on  the  heart  cannot  fail  in  producing 
anything  but  a  deleterious  effect. 

All  patients  suffering  from  tetanus  should  be  kept  in  a  quiet,  dark 
room,  and  all  kinds  of  excitement  must  be  carefully  avoided,  as  bodily 
and  mental  rest  are  important  elements  in  the  treatment.  As  mastica- 
tion is  impossible,  the  patient  must  be  nourished  with  liquid  food,  which 
he  can  sip  through  an  elastic  tube.  If  swallowing  is  impossible,  a  small 
elastic  tube  is  introduced  through  one  of  the  nostrils  into  the  stomach, 
and  food  is  administered  at  regular  intervals  by  this  method.  In  chronic 
tetanus  warm  baths  are  grateful  to  the  patient,  and  exercise  a  decided 
influence  in  ameliorating  the  symptoms.  The  surgical  treatment  of 
tetanus  has  j^ielded  no  better  results  than  tlie  internal  use  of  drugs.  In 
all  cases  the  infection-atrium  should  be  carefulh^  examined,  and,  if  neces- 
sary^, the  wound  or  local  lesion  should  be  thoroughly  disinfected,  as  this 
treatment  may  be  the  means  of  preventing  further  infection  from  this 
source.     Scars  should  be  excised  and  foreign  bodies  removed. 

Under  the  belief  that  tetanus  is  an  ascending  neuritis,  nerve-section, 
or  neurotomy,  has  been  practiced  for  the  purpose  of  preventing  further 
extension  of  the  inflammation  by  interrupting  the  continuity  of  the 
nerve;  but  the  results,  as  could  be  expected,  were  disappointing,  and  the 
operation  has  fallen  into  well-deserved  desuetude.    When  nerve-stretching 


TREATMENT.  401 

was  the  rage  in  the  treatment  of  all  kinds  of  nerve  affections  it  was  also 
applied  in  the  treatment  of  tetanus,  but  the  results  were  no  better  than 
after  neurotom}-.  Nocht  reported  24  cases  of  tetanus  treated  b}'  this 
method,  and  of  this  number  onl}-  4  recovered, — the  average  percentage 
of  recoveries  in  all  cases  of  tetanus  not  treated  by  surgical  resources. 
Amputation  is  only  indicated  in  cases  where  the  local  conditions  which 
gave  rise  to  tetanus  make  it  necessary-  to  resort  to  this  operation. 

as 


CHAPTER  XVI. 

Hydrophobia. 

Hydrophobia,  lyssa,  canine  madness,  and  rabies  are  S3'nonymous 
terms  used  to  designate  a  nervous  disease  caused  by  the  bite  of  a  rabid 
dog  or  other  animal,  attended  witli  violent  spasms  if  the  patient  attempts 
to  swallow  water  or  other  liquids,  and  by  embarrassment  of  respiration 
from  spasm  of  the  laryngeal  muscles.  This  disease  never  occurs  spon- 
taneously in  man,  but  is  always  the  result  of  inoculations  with  the  virus 
of  a  rabid  animal.  Although  this  disease  never  originates  elsewhere 
than  in  the  dog  and  animals  belonging  to  the  same  species,  the  wolf, 
fox,  and  jackal,  the  virus  of  rabies  is  capable  of  being  communicated  to 
all  warm-blooded  animals.  It  has  been  estimated  that  in  man  the  disease 
is  derived  in  nine  out  of  ten  cases  from  dogs  ;  sometimes  it  is  contracted 
from  cats,  and  sometimes,  but  ver}-  rarel}',  from  foxes  or  wolves.  The 
specific  virus  of  hydrophobia  appears  to  be  generated  in  the  glandular 
appendages  of  the  mucous  menil)rane  of  the  mouth  and  throat,  and  is 
transmitted  by  the  saliva  of  the  rabid  animal.  For  this  reason  it  has 
been  observed  that  inoculation  is  more  apt  to  take  place  from  a  bite  on 
an  uncovered  part  of  the  body,  as,  for  example,  on  the  hands  or  face, 
than  from  a  bite  inflicted  through  the  clothes,  as  in  the  latter  case  the 
greater  portion  of  the  saliva  is  deposited  in  the  clothing.  Not  every 
person  bitten  by  a  rabid  dog  necessarily  contracts  the  disease,  as 
statistics  have  shown  that  about  one-third  of  the  animals  and  human 
beings  bitten  by  mad  dogs  escape  all  danger.  This  partial  immunity  is 
explained  in  part  by  the  virus  being  diluted,  and  being  wiped  from  the 
teeth  of  the  rabid  animal  by  clothing  ;  and  also  bj^  well-ascertained  facts 
proving  the  absence  of  susceptibility  to  its  action  in  certain  individuals, 
both  in  animals  and  in  man. 

Renault's  careful  experiments  proved  that  one-fourth  of  the  inocu- 
lated creatures  escaped  the  effects  of  the  inoculations,  which  were  mortal 
in  the  other  three-fourths.  As  in  civilized  countries  the  disease  is  con- 
tracted almost  exclusively  from  rabid  dogs,  it  is  necessary  to  call  atten- 
tion to  the  symptoms  which  cliaracterize  the  disease  in  this  animal,  in 
order  that  it  may  be  recognized  in  time,  so  that  the  infected  animal  can 
be  isolated  and  kept  in  close  confinement  until  the  result  shall  prove  or 
disprove  the  correctness  of  the  diagnosis.     It  is  a  great  mistake  to  kill 

(403) 


404  PRINCIPLES   OF    SURGERY. 

an  animal  suspected  to  be  rabid,  until  b}^  careful  observation  continued 
for  some  length  of  time,  or  from  the  result  of  the  disease,  a  positive 
diagnosis  can  be  made,  and  thus  a  great  deal  of  unnecessary  fear  may 
be  avoided. 

HYDROPHOBIA    IN    THE    DOG. 

The  name  "  hydrophobia,"  meaning  literally  a  dread  of  fluids,  is  a 
proper  designation  for  the  disease  as  it  occurs  in  man,  because  a  peculiar 
dread  of  fluids  is  the  most  characteristic  symptom  of  this  disease  in  the 
human  being.  This  symptom  does  not  exist  in  the  dog  ;  hence,  in  this 
animal  we  should  speak  of  the  disease  as  rabies,  in  man  as  hydrophobia. 
Fleming,  who  is  an  acknowledged  autliority  on  everything  that  pertains 
to  hydrophobia,  makes  the  following  statement  in  reference  to  the  ability 
of  rabid  animals  to  take  fluids:  "  The  many  hundreds  of  rabid  dogs  seen 
by  Blaine,  Youatt,  and  others  did  not  evince  any  marked  aversion  to 
fluids.  On  the  contrary,  the  rabid  animal  is  generally  thirsty,  and  if 
water  be  oflfered  will  lap  it  up  with  avidity,  and,  at  the  commencement 
of  the  disease,  will  always  swallow  it.  When,  at  a  later  period,  the  con- 
striction about  the  throat,  wliich  is  symptomatic  of  the  malady,  renders 
swallowing  difficult,  the  animal  does  not  the  less  endeavor  to  drink,  and 
lappings  are  as  frequent  and  prolonged  as  deglutition  is  retarded.  Even 
then  we  see  the  suflering  creature,  in  despair,  plunge  its  entire  muzzle 
into  the  vessel,  and  gulp  at  the  water  as  if  determined  to  overcome  the 
spasmodic  closure  of  the  tliroat  by  forcing  down  the  fluid.  Tantalus 
did  not  experience  a  greater  torment  with  regard  to  water  than  does 
the  unlucky  dog."  The  excessive  sensibilit}'  to  pain  and  the  action  of 
tlie  mildest  external  irritants  so  characteristic  of  hydrophobia  in  the 
human  being  are  absent  in  the  rabid  dog.  The  animal  is  almost  insen- 
sible to  pain;  he  will  dash  himself  against  the  bars  of  his  kennel,  tear 
them  when  his  mouth  is  lacerated  and  bleeding,  and  he  has  been  known 
to  seize  a  red-hot  poker  in  his  mouth  and  hold  on  to  it,  apparently 
unconscious  of  suffering.  Rabies  in  the  dog  must  be  suspected  when 
the  animal  becomes  dull,  morose,  mopes,  and  avoids  his  master  and 
companions.  During  the  commencement  of  the  disease  the  animal  is 
exceedingly  restless,  and  is  alwa^'S  on  the  move,  prowling,  snapping,  and 
barking  at  imaginar^^  objects.  During  the  first  two  or  three  daj-s  there 
is  rarely  any  tendency  on  the  part  of  the  animal  to  bite,  nor  to  paroxysms 
of  uncontrollable  fury. 

The  danger  in  tliis  stage  to  man  and  other  animals  comes  from  lick- 
ing rather  than  biting,  for  there  is  a  propensity  to  extraordinar}'  demon- 
strations of  affection.  After  a  time,  however,  a  paroxysm  of  maniacal 
fury  comes  on,  generally  provoked  by  the  sight  of  another  dog.  When 
this  has  subsided  the  animal  again  becomes  controllable,  but  manifests 


HYDROPHOBIA    A   MICROBIC    DISEASE.  405 

a  strange  disposition  to  wander  from  place  to  place.  He  is  now  most 
dangerous.  With  a  slinking  and  troubled  aspect,  his  head  and  tail 
down,  his  eyes  suffused,  and  foam  at  his  mouth,  he  walks  or  trots  along, 
snapping  and  biting  at  real  and  imaginary  objects.  He  is  only  aggressive 
when  attacked,  and  then  his  fury  seems  unbounded.  When  tired  out 
from  inadequate  nourishment  and  the  ceaseless  wanderings,  he  drops 
exhausted  in  some  out-of-the-wa}',  solitary  corner,  and,  after  a  rest,  starts 
off  again  on  his  lonely  journey,  seemingl}-  impelled  by  some  irresistible 
force,  and  is  finally  killed  or  dies  of  exhaustion.  The  duration  of  the 
disease  in  the  dog  never  exceeds  ten  days,  and  in  the  majority  of  cases 
the  animal  dies  on  the  fourth  or  the  sixth  day  after  the  appearance  of 
the  first  symptoms.  From  a  stud}-  of  the  symptoms  in  this  animal  we 
can  readil}^  distinguish  three  stages  :  1.  Prodromal.  2.  Irritation.  3. 
Paralytic. 

During  the  prodromal  stage  the  most  noticeable  changes  refer  to  the 
altered  habits  of  the  animal,  while  the  stage  of  irritation  culminates  iu 
attacks  of  ungovernable  rage,  provoked  bj-  real  or  fancied  causes.  The 
last,  or  paralytic,  stage  precedes  death,  which  takes  place  from  exhaustion. 
The  period  of  incubation  in  the  dog  is  variable ;  it  is  usually  from  six 
to  twelve  v.eeks,  but  ma}'  extend  to  a  much  longer  period.  Frank,  from 
a  study  of  200  observed  cases  of  rabies  in  the  dog,  found  that  the  aver- 
age period  of  incubation  was  three  months  ;  the  extremes,  six  and  seven 
days,  and  eleven  months. 

HYDROPHOBIA    A   MICROBIC    DISEASE. 

Raynaud  and  Lannelongue  discovered  that  rabbits  could  be  success- 
fully inoculated  with  saliva  from  rabid  animals.  Pasteur  corroborated 
these  observations  by  his  own  experiments,  and  cultivated  from  the 
blood  of  the  infected  rabbits  in  veal-bouillon  a  micro-organism  which  in 
its  shape  resembled  the  figure  '•  8  ";  this  microbe  was  surrounded  by  an 
envelope  of  a  gelatinous  substance.  In  the  cultures  these  rods  are  said 
to  have  become  converted  into  chain  cocci.  Fowls  and  guinea-pigs  were 
not  found  susceptible  to  inoculations  with  cultures  of  this  microbe. 
After  Pasteur  had  regarded  these  micro-organisms  as  the  cause  of  h3"dro- 
phobia,  he  produced  the  same  disease  in  rabbits  by  inoculations  with 
saliva  from  health}-  persons.  Vulpian  also  succeeded  in  producing,  by 
inoculations  of  normal  saliva  in  rabbits,  a  disease  which  proved  fatal  in 
two  days  ;  and  witli  a  small  quantity  of  blood  taken  from  the  dead 
animals  the  disease  could  be  communicated  to  other  rabbits.  The  dis- 
ease thus  produced  was  probably  the  same  as  that  described  by  Stern- 
berg. This  observer  caused  marked  septicaemia  in  rabbits  by  injecting 
subcutaneously  his  own  saliva  in  small  doses.     Injections  of  1.25  to  1.75 


406  PRINCIPLES    OF    SURGERY. 

cubic  centimetres,  with  few  exceptions,  caused  death,  usually  within 
fort3'-eight  hours.  The  constant  and  characteristic  lesion  found  was  a 
diifuse  cellulitis,  or  iuflannnatory  oedema,  extending  in  all  directions 
from  the  point  of  injection,  attended  with  an  abundant  exudation  of 
bloody  serum,  swarming  with  micrococci.  Hsemorrhagic  extravasations 
in  the  connective  tissue,  and  in  various  organs,  were  of  frequent  occur- 
rence, and  changes  in  the  liver  and  spleen,  such  as  are  common  in  rapidly- 
fatal  septic  diseases,  were  generally  found.  The  disease  could  be  com- 
municated by  dipping  a  hypodermic  needle  into  the  blood  of  a  rabbit 
just  dead  from  the  result  of  an  injection  of  saliva;  inoculating  a  healthy 
rabbit,  a  rapidly-fatal  septicaemia  was  produced. 

Gibier  found,  in  the  brain  of  hydrophobic  animals,  round,  shining 
granules,  which  stained  slowly  and  imperfectly  in  aniline  dyes. 

Fol  stained  the  brain-substance,  according  to  Weigert's  method,  and 
discovered  in  the  hollow  spaces  of  the  neuroglia  groups  of  micrococci. 
The  same  microbe  he  found  also  in  the  nerve-fibres,  between  the  sheath 
and  axis-cylinder.  Bab^s  stained  the  specimens  according  to  Gram's 
method,  and  found  cocci  in  the  cells,  especially  those  of  the  surface  of 
the  brain.  The  cocci  looked  like  diplococci,  and  w^ere  alwaj's  found 
aggregated  in  flat  clusters.  Fol  and  Babes  claim  to  have  succeeded  in 
obtaining  a  culture  of  the  microbes  found  in  the  brain.  The  former 
used  for  nutrient  medium  a  filtrate  of  triturated  brain  and  parenchyma 
of  salivary  gland.  Of  8  dogs,  rats,  and  rabbits  inoculated  with  the  first 
culture,  5  died  of  well-marked  hydrophobia ;  of  8  dogs  inoculated  with 
the  second  culture,  four  died.  The  inoculations  were  alwa^^s  made  by 
infecting  the  brain  through  an  opening  in  the  skull.  The  microbes  in 
the  cultures  corresponded  in  shape  and  size  with  those  found  in  the 
brain  of  hydrophobic  animals.  The  third  series  of  cultures  produced 
only  negative  results.  The  microbes  in  these  cultures  were  more  readily 
stained  than  most  of  the  first  two  cultures.  Babes  cultivated  the 
microbe  upon  gelatin  and  coagulated  blood-serum,  to  which  was  added 
brain-substance  obtained  from  rabbits.  The  cultures  grew  slowl}',  and 
appeared  as  gray  spots.  Successful  inoculations  were  made  with  the 
second  and  third  generations. 

The  microbe  of  hydrophobia  exists,  but  so  far  it  has  not  been  discov- 
ered. That  hydrophobia  is  a  microbic  disease  can  no  longer  be  doubted. 
At  the  present  time  we  can  safely  assert,  without  fear  of  contradiction, 
that  the  essential  cause  of  this  disease  is  a  specific  virus,  which  can  only 
be  reproduced  within  the  living  organism.  As  a  small  quantity  of  this 
virus  introduced  into  the  tissues  can  result  in  the  most  serious  conse- 
quences, there  exists  no  doubt  that  it  possesses  the  properties  pertaining 
to  living  organisms,  more  especiallj^  the  capacity  of  reproduction  after 


CAUSES.  407 

its  entrance  into  the  body.  Tliat  tlie  disease  is  not  caused  by  preformed 
ptomaines,  communicated  from  the  saliva  of  rabid  animals,  is  shown  by 
the  variable  and,  on  the  whole,  long  stage  of  incubation  which  precedes 
all  true  infective  processes.  Another  convincing  proof  of  its  microbic 
origin  is  the  well-established  fact  that  the  disease  can  be  artificial!}'  pro- 
duced b}'  implanting  fragments  of  brain-  or  cord-  tissue,  taken  from 
animals  dead  of  rabies,  into  health}'  animals.  Furthermore,  the  blood 
and  secretions  of  a  rabid  animal,  its  flesh  and  viscera,  even  the  cooked 
flesh  of  a  rabid  ox,  when  eaten,  would  seem  to  be  capable  of  conveying 
the  disease.  A  pupil  at  the  veterinar}'  school  of  Copenhagen  inoculated 
himself  with  the  virus  by  cutting  his  finger  slightl}',  while  examining 
the  body  of  a  dog  that  had  died  of  rabies  on  the  evening  before  ;  the 
student  died  of  hydrophobia  in  six  weeks.  The  clinical  S3-mptoms,  as 
well  as  the  pathological  conditions  found  in  tlie  brain  and  spinal  cord  of 
h3-drophobic  patients,  bear  such  a  strong  resemblance  to  tetanus  that  it 
appears  probable  that  the  microbe  possesses  analogous  pathogenic  prop- 
erties, and  that  the  actual  development  of  the  disease  follows  the  action 
of  its  ptomaines  upon  the  central  nervous  system.  The  latent  stage  of 
the  disease,  or  the  long  duration  of  the  period  of  incubation,  depends 
either  upon  the  slow  growth  of  the  microbes  or  that  these  reach  the 
place  slowly  from  where  the}'  exert  their  specific  pathogenic  properties. 

CAUSES. 

The  microbe  of  hydrophobia  does  not  penetrate  the  intact  skin  or 
healthy  mucous  membrane;  hence  its  entrance  into  the  tissues  takes 
place  through  an  infection-atrium,  usually  a  punctured  wound  made  by 
the  bite  of  a  rabid  animal.  As  the  microbe  pre-exists  in  the  saliva  of 
the  rabid  animal,  inoculation  takes  place  at  the  time  the  wound  is 
inflicted.  Infection,  however,  can  take  place  by  the  deposition  of  the 
infected  saliva  upon  a  surface  from  which  absorption  can  take  place. 
This  can  occur  from  the  licking  of  a  wound  or  abraded  surface  by  an 
infected  dog,  as  happened  in  one  of  my  cases.  A  lady  of  rank  and 
fashion  had  a  pimple  on  her  face,  from  which  she  had  scratched  off  the 
head.  Hydrophobia  was  thus  contracted,  and  she  perished  by  this 
terrible  disease. 

SYMPTOMS    AND    DIAGNOSIS. 

Great  diversity  of  opinion  exists  as  to  the  length  of  the  period  of 
incubation  in  man.  In  the  2  cases  of  hydrophobia  that  have  come 
under  my  own  observation,  the  time  of  infection  and  the  onset  of  the 
disease  could  be  accurately  fixed,  and  in  both  of  them  the  stage  of  incu- 
bation lasted  forty-tivo  days.  In  106  cases  of  hydrophobia  in  human 
beings  of  all  ages,  collected  by  Bonley,  23  occurred  within  two  months 


4()<S  PRINCIPLES    OF    SURGERY. 

after  infection,  and  the  remainder  came  in  at  varying  periods,  the  longest 
time  noted  being  eight  months.  The  cases  reported  wliere  it  was  sup- 
posed tlie  disease  developed  some  ^^ears  after  tlie  persons  were  bitten 
by  a  dog  lack  accurac}^  of  observation,  and  either  the  diagnosis  was  not 
correct  or  infection  occurred  more  recently,  as  we  have  the  authority  of 
Fleming  that  the  disease  never  occurs  later  than  eight  mouths  after 
inoculation.  Age  appears  to  have  some  influence  in  modifying  tlie  dura- 
tion of  the  stage  of  incubation.  In  tlie  cases  where  the  length  of  this 
stage  could  be  accurately  ascertained,  in  patients  under  20  years  of  age 
the  mean  period  of  incubation  was  six  weeks  ;  from  20  up  to  72  it  was 
two  months  and  a  half.  Before  the  actual  development  of  the  disease  in 
man,  there  is  usually  a  period  of  a  few  days  during  which  ill-defined 
premonitor}'  S3'niptoms  can  be  detected  The  wound  through  which  the 
virus  entered  is  the  seat  of  a  sensation  of  uneasiness  and  itching,  and 
sometimes  of  actual  pain,  which  radiates  along  the  course  of  the  nerves 
of  a  limb.  The  cicatrix  often  presents  a  congested  appearance,  and  is 
tender  on  pressure.  The  patient  is  melancholic  and  irritable,  and  sleep 
is  disturbed.  The  first  characteristic  symptom  of  hydrophobia  in  man 
is  a  sense  of  tightness  and  choking  about  the  phnrynx,  attended  b}^  a 
hesitation  in  swallowing,  especially  of  liquids.  In  one  of  my  cases 
this  early  disturbance  of  the  function  of  the  muscles  of  deglutition 
made  it  possible  for  me  to  recognize  the  disease  a  few  hours  after  the 
attack  commenced.  The  patient  was  a  sailor,  about  30  years  of  age, 
who  sent  for  me  to  treat  him  for  a  supposed  cold.  The  onl}-  thing  he 
complained  of  was  a  sense  of  constriction  in  the  throat  and  difficulty 
in  swallowing.  In  examining  the  cavity  of  the  mouth  and  pharynx  for 
evidences  which  would  explain  the  existing  symptoms,  I  found  a  profuse 
salivary  secretion;  the  mucous  membrane  of  the  pharynx  was  congested, 
but  no  signs  of  deep-seated  inflammation  could  be  found  in  the  region 
of  the  tonsils.  M}'  suspicions  were  awakened  at  once.  I  asceitained 
that  six  weeks  before  a  small  pet  dog  owned  by  the  family  had  died 
after  a  few  days  of  illness,  and  that  one  day  during  this  time,  when  the 
patient  was  lying  on  his  back  on  the  floor,  the  dog  had  licked  a  small 
sore  on  the  anterior  surface  of  the  lobe  of  the  left  ear.  Requesting  the 
patient  to  drink  water  from  a  glass  which  I  handed  him,  I  noticed  a 
hesitation  on  his  part  to  com pl3' with  mj' wish  ;  but  finall}'  he  grasped 
the  glass  with  both  hands,  which  trembled  considerabl}',  and,  after 
waiting  for  the  proper  moment  to  come,  applied  it  rapidly  to  his  lips 
and  made  a  desperate  but  futile  effort  to  swallow ;  the  attempt  was 
repeated  several  times,  but  onl}'  a  veiy  small  amount  was  swallowed. 
The  next  group  of  muscles  to  become  affected  with  convulsive  spasms 
are  the  muscles  of  respiration  about  the  larynx.     The   sj'mptoms  of  a 


SYMPTOMS    AND    DIAGNOSIS.  409 

well-developed  case  of  hydrophobia  are  so  well  depicted  by  Fleming 
that  I  will  give  his  own  description.  ''The  difficulty  in  swallowing  rap- 
idl}'  increases,  and  it  is  not  long  before  the  act  becomes  impossible, 
unless  it  is  attempted  with  determination,  though  even  then  it  excites 
the  most  painful  spasms  in  the  back  of  the  throat,  with  other  indescriba- 
ble sensations,  all  of  which  appal  the  patient  and  cause  him  to  dread  the 
very  thought  of  liquids.  Singular  nervous  paroxysms  or  tremblings 
becojnc  manifest,  and  sensations  of  stricture  and  oppression  are  felt 
about  tlie  throat  and  chest.  The  breathing  is  painful  and  embarrassed, 
and  interrupted  with  frequent  sighs  or  a  peculiar  kind  of  sobbing  move- 
ment, or  catching  of  the  breath  ;  there  is  a  sensation  of  impending  suffo- 
cation and  of  necessity  for  fresh  air.  Indeed,  the  most  marked  symptoms 
consist  in  a  horriblj'  violent  convulsion  or  spasm  of  the  muscles  of  the 
larynx  and  pharynx,  or  gullet,  b3'  which  swallowing  is  prevented,  and  at 
the  same  time  the  entrance  of  air  into  the  windpipe  is  greatly  retarded. 
Shuddering  tremors,  sometimes  amounting  to  general  convulsions,  run 
through  the  whole  frame,  and  a  fearful  expression  of  anxiety,  terror,  and 
despair  is  depicted  on  the  countenance." 

Frothing  at  the  mouth  is  rarel}^  observed,  but  the  viscid,  tenacious 
mucus  in  the  fauces  and  the  profuse  salivarj^  secretion  are  frequently  for- 
cibly' ejected  by  hawking  and  spitting.  Shortly  before  death  the  patient's 
mouth  is  often  full  of  this  mucus  or  froth,  which  in  some  cases  is  tinged 
with  blood.  The  pulse  at  first  is  not  much  changed  in  force  and  fre- 
quency, but  as  the  disease  advances  it  becomes  feeble  and  rapid,  and 
often  intermittent.  The  temperature  is  always  increased.  In  both  of 
my  cases  the  thermometer  registered  from  101°  to  103°  F.  at  different 
times  in  the  axilla.  A  post-mortem  temperature  of  106.2°  F.,  taken  in 
the  rectum  immediatel}'  after  death,  has  been  recorded. 

Occasionally  the  patient  has  hallucinations  of  sight  and  hearing,  but 
usually  the  mental  faculties  are  not  much  impaired.  One  patient,  al- 
luded to  by  Trousseau,  heard  the  ringing  of  bells,  and  some  mice  run 
about  on  his  bed.  To  the  by-stander  the  most  distressing  phenomenon 
presented  by  hydrophobic  patients  is  the  fear  of  impending  death,  which 
is  usually  manifested  soon  after  the  attack,  and  remains  throughout  the 
whole  course  of  the  disease.  No  kinds  of  assurances  or  consolation  are 
able  to  dispel  it.  Deatli  occurs  from  complete  exhaustion,  in  most  cases 
attended  by  well-marked  evidences  of  asphyxia  from  spasm  of  the  glottis  ; 
sometimes  a  convulsion  is  the  final  S3mptom,  as  in  tetanus. 

The  differential  diagnosis  between  hydrophobia  and  tetanus  is  not 
alwaA's  eas3-.  In  both  diseases  the  stage  of  incubation  is  variable,  and 
both  :ire  characterized  by  excessive  excitability  of  the  cerebro-spinal 
centre,  as  is  evident  from  the  muscular  spasms  and  great  hypeni^sthesia 


410  PRINCIPLES   OF    SURGERY. 

of  the  entire  surface  of  the  body  during  the  stage  of  irritation.  In 
hydrophobia  infection  always  takes  place  from  the  bite  of  a  rabid  animal, 
and  the  difficulty  in  swallowing  is  not  caused  by  spasm  of  the  pharyn- 
geal muscles,  but  by  tonic  contraction  of  the  muscles  of  mastication, 
notably  the  masseters.  In  tetanus  respiration  is  impaired  by  rigidity  of 
the  respiratory  muscles  of  the  chest ;  in  hydrophobia  by  spasmodic  con- 
tractions of  the  respiratory  muscles  of  the  larynx.  Acute  softening  of 
the  brain,  and  meningitis  affecting  the  base  of  the  brain  and  upper  por- 
tion of  the  spinal  cord,  may  give  rise  to  symptoms  that  bear  a  faint  re- 
semblance to  the  clinical  picture  of  hydrophobia,  but  a  careful  study  of 
the  symptoms,  individually  and  collectively,  will  disclose  the  real  nature 
of  the  case  under  consideration.  A  purely  neurotic  affection  has  been 
described  as  li/ssa  nervosa  falsa,  which,  it  has  been  said,  resembles  genu- 
ine hydrophobia  closely.  Such  cases  are  undoubtedly  one  of  the  mani- 
fold manifestations  of  hysteria  ;  and,  if  so,  it  can  be  differentiated  from 
true  hydrophobia  by  the  absence  of  fever  and  by  the  fact  that  the  mus- 
cular spasms  are  not  limited  to  the  muscles  of  deglutition  and  the  mus- 
cles of  the  larynx.  Trousseau  speaks  of  lyssa  nervosa  falsa  as  a  mental 
hydrophobia.  Fayrer  describes  a  case  of  this  kind  in  a  young  Scotchman 
in  India,  and  Bollinger  quotes  a  case  of  a  boy  who  was  twice  frightened 
into  simulated  hydrophobia. 

In  making  a  positive  final  diagnosis  of  hj'drophobia,  it  is  necessary 
to  establish,  in  tlie  first  place,  the  fact  that  infection  occurred  from  a 
rabid  animal  within  eight  months  from  the  development  of  the  disease  ; 
and,  in  the  second  place,  it  is  necessary  to  prove  the  existence  of  spasms 
of  the  muscles  of  deglutition  in  attempts  to  swallow  liquids  ;  and  if  at 
the  same  time  spasms  of  the  muscles  of  the  larynx  interfere  with  the 
function  of  respiration,  all  doubt  as  to  the  nature  of  the  difficulty  has 
been  removed. 

PROGNOSIS. 

If  any  doubt  existed  as  to  the  nature  of  the  case  during  life,  an  early 
fatal  termination  wull  corroborate  the  suspicions  that  may  have  been  en- 
tertained. Decroix  reports  9  cases  of  spontaneous  recovery  in  dogs. 
In  man  this  terrible  disease  is  invariably  fatal ;  there  is  no  authentic 
instance  on  record  of  recovery  from  genuine  hydrophobia.  Death  results 
unexpectedly,  suddenly,  or  from  apoplexy,  asphyxia,  or  exhaustion,  in 
from  twelve  hours  to  six  days  from  the  appearance  of  the  first  symptoms. 
The  mean  duration  of  tlie  disease  is  about  four  days  One  of  my  patients 
died  on  the  fourtii  and  the  other  on  the  fifth  day  after  the  attack.  In 
90  cases  collected  by  Bonley,  death  occurred  in  74  during  the  first  four 
days,  the  largest  proportion  of  these  being  on  the  second  and  third  days. 
In  only  16  was  life  prolonged  beyond  the  fourth  da3\ 


PATHOLOGY    AND    MORBID    ANATOMY, 


411 


PATHOLOGY  AND  MORBID  ANATOMY. 
Hydrophobia,  like  tetonus,  to  which  disease  it  is  so  closely  allied  in 
many  respects,  is  characterized  by  the  absence  of  gross  pathological 
changes  in  the  nervous  centres  and  at  the  primary  seat  of  infection.  Tlie 
scar  which  marks  the  wound  or  lesions  through  which  infection  occurred 
may  be  red  and  sliglitly  swollen,  but  these  changes  are  not  pres^ent  in 
all  cases.  Hydrophobia  is  a  disease  in  which  there  is  every  indication 
of  irritation  of  certain  nerve-centres  and  of  a  greatly  increased  reflex 
irritability.  The  centres  irritated  here  are  less  those  of  the  cerebral 
hemispheres  than  of  the  spinal  cord  and  medulla  oblongata.     The  symp- 


^rW^ 


->p^^^^m 


^c-"^ 

,*>- 


^f 


0^^ 


-^tf 


T^' 


.^^ 


J'***«i.i,iu  I  m...ili 


Fig.  90.— a  Blood-vessel  from  Medttlla  Oblongata  in  a  Case  of  Hydrophobia. 
Large  Numbers  of  Round  Cells  are  Seen  in  its  Sheath.    x350.  (CocUes.) 

toms  point  mainly  to  the  medulla  oblongata,  and  after  death  well-defined 
vascular  lesions  can  be  detected  in  this  structure  by  means  of  the 
microscope. 

Similar  lesions,  but  less  marked,  can  be  found  in  the  spinal  cord,  and 
still  to  a  lesser  degree  in  the  other  parts  of  the  nervous  system.  The 
most  prominent  condition  is  an  accumulation  of  leucocytes  around 
the  vessels  in  the  substance  of  the  cord  and  medulla  oblongata.  Where 
the  local  lesion  is  most  advanced  the  vessels  are  surrounded  by  several 
layers  of  leucocytes,  which  would  indicate  that  the  microbe  of  hydro- 


41-2 


PHINCIl'LES   OF    SURGERY. 


pliobiii  or  its  ptomaines  protliicc  an  alteration  of  the  capillary  wall  of 
suflicient  intensit3'  to  entitle  the  i)roeess  to  be  called  intlammation.  An 
increase  of  leucoc3tes  is  evident  everjAvliere,  so  much  so  that  the  collec- 
tions which  can  be  found  in  ditferent  parts  have  been  called  miliary 
abscesses.  As  the  leucocytes  show  no  evidences  of  even  approaching 
transformation  into  i)us-corpuscles,  these  aggregations  of  leucocytes  do 
not  deserve  the  name  of  abscesses.  Klebs  is  of  the  opinion  that  the  mi- 
crobe of  hydrophobia  does  not  enter  the  circulation  directly,  but  invades 
in  preference  the  lymphatic  vessels,  as  he  found  general  lymphatic  en- 
gorgement in  a  recent  case.  The  same  author  also  discovered,  particu- 
larly in  the  submaxillary  gland,  deposits  of  finely  granular,  strongly  re- 
fractive corpuscles  of  a  faint,  brownish  color,  closely  pncked  together  in 


Fig.  91.— From  the  .Salivary  Gland  in  a  Ca.se  of  Hydrophobia.  In  the 
Middle  is  the  Portion  of  a  Duct;  abundant  Round  Cells  around 
it  as  well  as  the  Glandular  Structures  shown  in  Outline.  x350. 
(Coates.) 


clusters  and  rows,  which  he  regards  as  possibly  the  vehicles  for  the 
transportation  of  the  specific  virus.  Well-marked  evidences  of  leuco- 
cytes have  been  found  by  many  in  the  salivarj^  glands. 

There  is  hypersemia  and  oedema  of  the  substance  of  the  brain, 
medulla  oblongata  and  cord,  and  of  their  membranes  ;  deep-red  injection 
of  the  mucous  membrane  of  the  phar^'nx  and  epiglotis,  and  sometimes 
recent  swelling  of  the  tonsils,  follicular  glands  of  the  tongue,  pharyngeal 
follicles,  and  of  the  lympiiatic  glands  in  the  neighborhood  of  the  jaw. 
The  stomach  and  intestines  show  decided  injection,  and  often  hsemor- 
rhagic  extr:ivasations.  The  lungs  are  charged  with  blood,  with  frequent 
points  of  c:i[)illary  haemorrhage,  and  sometimes  emphysema  as  a  result 
of  the  dyspncea.  In  the  kidneys,  also,  there  are  signs  of  irritation  in 
the  form  of  dilatation  of  vessels  and  haemorrhasfe.     According^  to  Bol- 


TREATMENT.  413 

linger,  the  anatomical  picture  bears  the  strongest  resemblance  to  that 
seen  in  cases  of  death  from  asphyxia  or  thirst.  The  conditions  found, 
post-mortem,  furnish  an  illustration  that  here  an  intense  irritant  is  cir- 
culating in  the  blood,  and  the  intensit}-  of  it  ma}-  be  judged  from  the 
fact  that  all  these  ver}'  marked  appearances,  although  nearl}-  all  of 
them  recognized  onl}"  b}-  the  use  of  the  microscope,  occur  in  the  short 
space  of  three  or  four  da^'s. 

TREATMENT. 

As  hydrophobia  is  an  absolutely-  fatal  disease,  the  treatment  resoh^es 
itself  into  prophylactic  measures  to  prevent  the  disease,  and  means  of 
palliation  after  it  has  developed. 

Prophylactic  Treatment. — Tlie  most  effective  prophylactic  measures 
consist  in  preventing  the  spread  of  the  disease,  among  animals,  by  the 
killing  or  strict  isolation  of  animals  which  present  symptoms  of  rabies. 
If  animals,  which  are  suspected  of  being  rabid,  are  known  to  have 
bitten  persons,  the}'  sliould  not  be  killed  at  once,  but  should  be  kept  in 
close  confinement  unknown  to  the  injured  person,  until,  by  observation 
or  the  course  of  the  disease,  a  positive  diagnosis  can  be  made.  As  soon 
as  a  positive  diagnosis  of  rabies  can  be  made,  then  the  animal  should  be 
killed  to  prevent  any  further  possibilitj'  of  infecting  other  animals  or 
persons.  If  a  person  is  bitten  b}'  an  animal  wliich  presents  suspicious 
symptoms,  no  time  should  be  lost  to  prevent  infection  by  removing  or 
destroying  the  virus. 

(a)  Excision  of  Wound. — As  the  virus  of  hydrophobia  appears  to  be 
slowly  dirt'used  in  the  tissues,  thorough  local  treatment  of  the  wound 
ma}-  prove  successful  in  preventing  infection,  even  if  resorted  to  several 
hours  or  days  after  inoculation  has  occurred.  As  soon  as  possible  after 
the  bite  has  been  inflicted,  a  constrictor  should  be  applied  on  tlie  proxi- 
mal side  of  the  wound  and  medical  aid  summoned  without  delay.  In 
the  meantime  an  attempt  should  be  made  to  remove  the  virus  from  the 
wound  by  suction.  In  recent  cases  the  simplest  and  safest  treatment 
consists  in  excising  the  tissues  in  the  immediate  vicinit}-  of  the  puncture, 
and  after  thorough  disinfection  close  the  wound  with  sutures. 

(bj  Cauterization  of  Wound. — The  same  object  is  accomplished,  but 
with  a  lesser  degree  of  certainty,  by  cauterization.  Tlie  most  efficient 
caustic  is  the  actual  cauter}'.  With  the  knife-point  of  a  Paquelin  cautery 
the  wound  is  deeply-  cauterized,  and  the  resulting  eschar  is  protected 
against  infection  with  pus-microbes  by  an  antiseptic  dressing.  Of  the 
chemical  caustics  the  most  valuable  are  caustic  potassa,  nitric  acid,  sul- 
phuric acid,  and  nitrate  of  silver,  their  efficiency  being  estimated  in  the 
order  named.  The  authority-  for  excision  and  thorough  cauterization,  as 
prophylactic  measures,  is  to  be  found  in  the  fact  that,  of  134  collected 


414  PRINCIPLES   OF    SURGERY. 

cases,  in  which  bites  of  mad  clogs  were  cauterized,  68  escaped  and  42 
died, — a  degree  of  immunity  far  above  the  average,  which  is  33  per  cent. 
(Bonley.) 

(c)  Prophylactic  Inoculations. — Pasteur  has  shown,  by  a  long  series  of 
inoculations,  made  first  in  monkeys,  rabbits,  and  guinea-pigs,  and  later 
exclusively  in  rabbits,  that  if  the  virus  of  hydrophobia  is  introduced 
into  the  brain  of  these  animals  the  disease  is  invnriably  produced  after 
a  fixed  period  of  incubation.  As  the  period  of  incubation  in  successive 
inoculations  in  the  same  animal  is  shortened,  we  must  take  it  for  granted 
that  the  virulence  of  the  material  is  increased.  In  the  rabbit  the  first 
inoculation  under  the  dura  mater  is  followed  by  a  period  of  incubation 
of  fourteen  days'  duration,  which,  in  successive  inoculations  in  the  same 
animal,  is  reduced  to  seven  days.  Back  inoculations  in  dogs  produce  in 
these  animals  fatal  rabies  in  the  same  length  of  time.  Pasteur  made  an 
additional  important  discovery,  as  he  found  that  the  spinal  cord  of  the 
inoculation  rabbits,  increased  in  virulence  by  successive  inoculations,  is 
again  diminished  in  its  virulence  by  preserving  it  in  dr}'  air,  gunrding  at 
the  same  time  against  contamination  with  other  micro-organisms.  This 
discover}'  led  to  a  method  b}-  which  the  virulent  action  of  such  prepa- 
rations can  be  accurately  graded,  inasmuch  as  the  action  of  the  spinal 
cord,  in  the  drying-room,  in  7  to  8  days  is  reduced  from  its  highest  degree 
of  virulence  to  nil.  By  using  the  spinal  cord  of  rabbits  treated  in  this 
manner  in  different  strengths,  at  first  weak  and  then  gradually  stronger 
preparations,  it  was  found  possible  to  render  animals  immune  to  the 
action  of  inoculation  material  of  the  highest  potency.  By  this  method 
Pasteur  succeeded  in  creating  absolute  immunit}'  against  the  strongest 
hydrophobic  virus  in  50  dogs.  The  success  of  these  prophylactic  inocu- 
lations in  animals  enabled  Pasteur  to  resort  to  the  same  method  of 
treatment  in  persons  bitten  by  rabid  animals,  as  the  long  stage  of  incu- 
bation made  it  possible  to  carry  out  this  treatment  before  the  actual 
development  of  the  disease  was  expected.  The  first  human  being  sub- 
jected to  this  treatment  was  on  5\\\y  5,  1885,  and  from  that  time  until 
the  close  of  the  year  1889  2682  persons  bitten  by  rabid  animals,  or 
animals  that  were  suspected  of  being  mad,  with  the  result  that  of  this 
large  number  only  31  died,  equiA'alent  to  1.15  per  cent.,  while  the  general 
mortality  in  persons  under  similar  circumstances  without  such  prophy- 
lactic inoculations  has  been  at  least  16  per  cent.  The  danger  is  alwaj^s 
greatest  when  the  bite  is  inflicted  by  rabid  wolves.  Pasteur  collected 
100  cases  of  persons  bitten  b}'  rabid  wolves,  and  of  this  number  not  less 
than  82  died.  Pasteur  had  an  opportunity  to  submit  to  his  treatment 
38  persons  bitten  by  rabid  wolves,  and  of  this  number  only  3  died, — a 
mortality  of  7.89  per  cent. 


TRlEATIVIENT.  415 

The  following  tables  represent  Pasteur's  work  for  four  3'ears  : — 


Table  A. 

Table  B. 

Table  C. 

Total. 

Yeabs. 

5 

11 
1= 

i 
s 

>>1 

-< 

S2 

u 

73 

s 

•ti 

■2  0 

0  ^< 
g  ft 

2^3 

13 

s 

1? 

c  t- 

1886  .     . 

1887  .     . 

1888  .     . 

1889  .     . 

231 
357 
402 
346 

3 

2 

6 
2 

1.30 
0..56 
1.49 
0.58 

1926 

1156 

972 

1187 

19 

10 

2 

2 

0.99 
0.86 
0.21 
0.17 

514 
257 
248 
297 

3 

1 
1 
2 

0.58 
0.39 
0.40 
0.67 

2671 
1770 
1622 
1830 

25 

13 

9 

6 

0.94 
0.73 
0.55 
0.33 

Total  .    . 

1336 

13 

0.97 

5241 

33 

0.63 

1316 

7 

0.53 

7893 

53 

0.67 

The  bites  have  been  divided  into  three  categories, — 

1.  Those  of  the  head  and  face ; 

2.  Those  of  the  hands  ; 

3.  Those  of  the  limbs  and  ti'unk, — with  the  following  result : — 


Tables  A  and  B. 

Table  C. 

Total. 

5 

S 

is 

■6 
S 

^'2 

ilS 

0  ^ 

1.  Head  and  face 

2.  Hands 

3.  Limbs  and  trunk     .... 

593 

3768 
2216 

14 

26 

6 

2.36 
0.69 
0.27 

79 
619 

618 

1 
3 
3 

1.27 
0.48 
0.48 

672 

4387 
2834 

15 

29 

9 

2.23 
0.66 
0.32 

Total 

6577 

46 

0.70 

1316       7      0.53 

7893 

58 

0.67 

Table  A  comprises  those  persons  bitten  by  animals  determined  to 
be  rabid  by  experiments  in  rabbits,  made  in  the  laboratory,  or  by  the 
death  of  other  animals,  or  persons,  bitten  by  the  same  animal. 

Table  B  comprises  those  persons  bitten  by  animals  demonstrated  to 
be  rabid  by  the  examination  of  a  veterinarj'  surgeon,  or  by  the  clinical 
signs  shown  during  life. 

Table  C  comprises  those  persons  bitten  by  animals  suspected  to  be 
rabid. 

These  results  must  convince  the  most  skeptical  of  the  practical 
utilit}^  of  Pasteur's  prophylactic  treatment  against  hj'drophobia,  and, 
although  the  method  will  not  be  perfect  until  the  microbe  of  this  disease 
is  discovered  and  mitigated  (pure  cultures  are  emplo3-ed),  this  crude 
method  must  be  viewed  as  a  great  boon  to  a  class  of  patients  otherwise 
exposed  to  the  risks  of  contracting  the  most  terrible  and  hopeless  of  all 


416  PHINCIPLES    OF    SURGERY. 

diseases.  Pasteur  institutes  have  sprung  up  in  different  parts  of  the 
civilized  world,  and  the  accumulated  experience  of  all  those  engaged  in 
this  kind  of  work  bears  strong  testimony  in  favor  of  the  proph}' lactic 
inoculations  against  hydrophobia  as  taught  and  practiced  by  Pasteur, 
At  the  bacteriological  laboratory  in  Cuba  306  persons  liave  been  treated 
by  the  "  double  intensive "  plan.  Of  these  only  2  died  after  going 
through  the  full  course, — a  mortality  of  1.63  per  cent.  All  these  cases 
were  bitten  by  dogs  proved  experimentally  and  clinically  to  be  rabid,  or, 
at  anjf  rate,  suspected.  That  the  inoculations  were  conducted  with  due 
conservatism  is  indicated  by  the  fact  that  only  306  persons  were  treated 
out  of  700  applicants.  Some  of  the  failures  Pasteur  attributes  to  the 
long  intervals  between  the  prophylactic  inoculations,  and  in  grave  eases 
he  now  advises  that  successive  inoculations  should  be  made  with  cord- 
substance  twelve,  ten,  and  eight  days  old,  during  the  first  twentj^-four 
hours  ;  on  the  second  da}^  with  material  six,  four,  and  two  da3"S  old  ;  on 
the  eighth  da}-  with  material  one  day  old,  to  be  followed  by  two  similar 
series  of  inoculations.  By  following  this  energetic  plan  of  prophjdactic 
treatment  he  has  been  able  to  secure  protection  even  in  the  most  urgent 
cases ;  that  is,  in  cases  where  the  stage  of  incubation  had  nearly 
terminated. 

Palliative  Treatment, — The  nature  of  the  disease  should,  under  no 
circumstances,  be  disclosed  to  the  patient,  as  the  people,  high  and  low, 
educated  and  ignorant,  are  only  too  familiar  with  the  terrible  suffering 
caused  by  this  affection  and  its  absolute  certaint}'  of  a  fatal  termination 
in  a  few  days.  In  one  of  my  cases  the  patient  had  been  made  acquainted 
with  the  character  of  the  ailment,  and  begged  piteously  that  his  life 
might  be  terminated  by  the  administration  of  chloroform,  knowing  well 
that  the  intense  suffering  would  continue  to  the  last  moment.  As  light, 
draughts  of  air,  and  noise  of  every  kind  increase  the  suffering  by  exag- 
gerating convulsive  spasms,  these  aggravating  causes  should  be  elimi- 
nated from  the  patient's  room,  and  only  a  limited  number  of  persons 
should  be  admitted  to  render  the  necessary"  assistance  and  carry  out  the 
directions  of  the  attending  phj'sician.  As  the  saliva  of  hydrophobic 
patients  contains  the  specific  virus,  those  placed  in  charge  of  the  patient 
should  protect  themselves  against  inoculation  by  preventing  the  contact 
of  the  saliva  with  abraded  surfaces,  or,  still  better,  b}^  covering  an}^ 
abrasions  which  may  exist  with  a  coUodiura  dressing.  Thirst  is  quenched 
by  administering  water  per  rectum.  Medicines  b}'  the  mouth  should  not 
be  given,  as  every  attempt  at  swallowing  brings  on  violent  spasms  of  the 
muscles  of  deglutition  and  the  respiratory  muscles  of  the  larynx.  Mor- 
phia combined  with  small  doses  of  atropia  should  be  given  subcutaneously 
in  such  doses  and  at  such  intervals  as  will  procure  rest.     The  subcu- 


TREATMENT.  417 

taneous  administration  of  quinine  and  woorara  has  been  advised,  but 
both  of  these  remedies  are  more  harmful  than  useful,  and  neither  of 
them  either  add  anj-thing  to  the  duration  of  life  or  alleviation  of  sufter- 
ing.  The  onlv  reraedj'  which  can  be  relied  upon  to  afford  prompt  relief 
is  chloroform  by  inlialation.  Ether  should  never  be  used,  as  the  hyper- 
semic  condition  of  the  brain  and  spinal  cord  which  is  present  in  every 
case  of  hydrophobia  sufticientl}'  contva-indicates  its  use.  The  inhalation 
of,  chloroform  must  be  conducted  b}^  an  assistant  or  a  competent,  re- 
liable nurse,  and  should  never  be  carried  beyond  the  point  wlure  relief 
is  afforded,  and  it  siiould  be  repeated  as  often  as  the  paroxysms  return. 

27 


CHAPTER  XVII. 

Surgical  Tuberculosis. 

Tubercular  lesions  furnish  a  most  excellent  illustration,  clinicall}' 
and  under  the  microscope,  of  the  origin,  course,  termination,  and  tissue 
changes  of  what  is  kncnvn  as  chronic  intlnmniation.  A  histological 
description  of  a  tubercular  nodule  is  a  description  of  tlie  pathology  of 
chronic  inflammation.  Tuberculosis  in  all  its  forms  is  caused  by  a 
specific  microbe,  the  action  of  which  upon  the  tissues  produces  his- 
tological and  vascular  changes  which  are  characteristic  of  chronic 
inflammation.  Of  all  the  microbic  diseases,  with  the  exception  of  sup- 
puration, tuberculosis  is  of  the  greatest  interest  and  importance  to  the 
surgeon.  Of  the  greatest  interest  because  the  tubercular  lesions  which 
come  under  his  care  are  more  clearly  understood  from  a  bacteriological 
stand-point  tlian  most  of  the  other  surgical  diseases,  and  of  the  greatest 
importance  on  account  of  their  great  frequenc}'.  That  large  class  of 
ill-defined  lesions  which  were  grouped  under  that  indefinite  and  vague 
term  scrofula,  in  the  text-books  of  but  a  few  years  ago,  haA'e  been  shown 
b}"-  recent  research  to  be  identical  with  the  recognized  forms  of  tuber- 
culosis,, etiologically,  clinicall}^  and  anatomically.  In  this  chapter  I 
shall  aim  to  give  a  brief  description,  from  a  bacteriological  and  clinical 
stand-point,  of  such  localized  tubercular  lesions  which,  by  general 
consent,  are  regarded  as  surgical  affections  and  requiring  surgical 
procedures  in  their  successful  treatment. 

HISTORY  OF  THE  MICROBIC  ORIGIN  OF  TUBERCULOSIS. 
The  first  inoculation  experiments  with  tubercular  products  were 
made  by  Kortum  in  1789,  and  Cruveilhier  in  1826.  In  1834  Erdt  suc- 
ceeded in  producing  numerous  nodules  in  the  lungs  of  horses  b3'  inocu- 
lating them  with  tubercular  pus,  and  Klencke,  in  1843,  produced 
tuberculosis  in  rabbits  by  intra-venous  injections  of  tubercular  matter. 
The  results  obtained  from  the  crude  inoculation  experiments  which 
were  made  years  ago  )iy  Villemin  pointed  strongl}^  towaixl  the  infec- 
tiousness of  tuberculosis.  Villemin's  experiments  consisted  in  the 
subcutaneous  insei'tion,  behind  the  ear  of  rabbits,  of  fragments  of 
tubercular  tissue  or  fluid  taken  from  tlie  cavity  of  a  tubercular  luno- 
recently  removed  from  a  patient  who  had  died  of  pulmonary  phthisis. 

(419) 


420  PRINCIPLES   or    SUIIGERT. 

The  first  nnimal  thus  infected  was  killed  three  and  a  half  months  after 
inoculation.  The  lungs  and  most  of  the  internal  organs  were  found 
diffusely  infiltrated  with  miliary  tubercle.  His  numerous  later  experi- 
ments yielded  similar  results,  and  led  hini  to  the  following  conclusions  : 
"  Phthisis  of  the  lungs  (like  tubercular  diseases  in  general)  is  a  specific 
infection.  Its  etiology  depends  on  an  inoeulable  agent.  It  can  be 
readil}^  communicated  from  man  to  animal  by  inoculation." 

Yogel  repeated  the  experiments  of  Yillemin  on  horses  without 
success.  BifH,  Verga,  and  Sangalli  experimented  on  mules,  cows,  sheep, 
dogs,  cats,  mice,  and  chickens  with  negative  results.  The  experiments 
of  Langhans  led  him  to  the  conclusion  that  tubercle  could  not  be  com- 
municated in  the  manner  described  b}^  Villemin.  He  claimed  that  the 
inoculation  material  acted  only  the  part  of  a  foreign  bodj',  the  inflam- 
mation following  its  insertion  into  the  tissues  differing  in  no  way  from 
the  ordinar}'  forms  of  inflammation.  Among  those  who  made  successful 
inoculation  experiments,  and  adopted  the  doctrines  advanced  by 
Yillemin,  may  be  mentioned  Hevard  and  Cornil,  Hoffmann,  Cohn,  Behier, 
Empis,  Mantagazza,  Bizzozero,  Lebert  and  Wj^ss,  Klebs,  Koester, 
Waldenburg,  Bijuen,  Simon,  Sanderson,  W.  Fox,  Papillon,  Nicol,  and 
Laveran.  Hevard  and  Cornil  were  able  to  propagate  them.  They  inocu- 
lated witli  genuine  tubercular  material,  but  failed  with  cheesy  products. 
Marcet  inoculated  11  guinea-pigs  with  the  sputa  of  phthisical  patients, 
and  in  10  of  them  the  experiment  proved  successful.  Cohnheim  injected 
tubercular  material  into  the  anterior  chamber  of  the  eye  in  rabbits,  and 
succeeded  in  producing  the  disease  artificiallj'  in  this  manner..  Hueter 
produced  tulierculosis  of  the  iris  b}"  inserting  into  the  anterior  chamber 
of  the  e3'e  in  rabbits  fragments  of  tubercular  tissue.  Toussaint  showed 
that  true  tubercle,  both  in  man  and  animals,  reproduces  itself  indefinitely 
with  absolutely  constant  and  identical  properties,  and  that  it  is  quite 
capable  of  being  transmitted  from  animal  to  animal  without  losing  its 
virulence. 

Krishaber  and  Dieulefoy  experimented  on  monkeys,  and  the  results 
obtained  led  to  the  conclusions :  1.  That  human  tubercle,  when  inocu- 
lated, kills  a  monke}^  in  nine  out  of  ten  cases,  with  lesions  analogous  to 
those  met  in  man.  2.  The  effect  of  the  inoculation  varies  according 
to  the  substance  employed ;  the  gray  granulation  is  most,  and  the 
pulmonary  parenchyma  least,  infectious.  Schliller  and  Lentz  made 
successful  inoculations  with  blood  taken  from  tuberculous  rabbits. 
Lippl,  Schwenniger,  Tappeiner,  and  Weichselbaum  succeeded  in  pro- 
ducing the  disease  in  animals  by  inhalation.  Successful  feeding  experi- 
ments were  made  by  Chaveau,  Aufrecht,  and  Bollinger.  Since  Yillemin 
announced  the  inoculability  of  tuberculosis,  diligent  search  was  made 


HISTORY    OF    THE    MICROBIC    ORIGIN    OF    TUBERCULOSIS.        421 

to  discover  and  isolate  a  specific  micro-organism  which  should  be 
characteristic  of  this  disease. 

The  first  cultivation  experiments  were  made  bj-  Klebs  in  1877.  He 
found,  b}'  examining  fresh  specimens  of  tubercle  of  human  beings,  that 
they  invariabh"  contained  bacteria.  He  cultivated  them  in  egg-albumen 
and  Bergmann's  culture  fluid,  and  found,  by  experiment,  that  the  cultures 
produced  the  same  effect  in  causing  disease  b^^  inoculation  as  the  tissues 
from  which  they  were  grown.  Injections  of  the  culture  under  the  skin, 
into  the  muscles,  lungs,  pleural  and  peritoneal  cavities,  caused  death  of 
the  animals  from  tuberculosis.  Cultures  made  in  a  similar  manner  from 
scrofulous  glands  and  lupus-tissue  produced  the  same  effect  in  animals. 
Max  Schiiller  repeated  the  experiments  of  Klebs  with  the  same  results. 
He  described  the  specific  microbe  as  round  and  rod-shaped  bacteria,  the 
rods  bulbous  at  both  ends,  composed  of  two,  seldom  more,  spherical 
bodies.  He  found  these  microbes  in  great  abundance  in  tubercular  joints 
and  tubercular  foci  in  bone.  He  produced  the  disease  artificial!}'  in 
animals  which  were  previously  inoculated  by  making  contusions  of 
joints.  Other  workers  in  the  same  field  advanced  theories,  found  and 
described  microbes,  which  were  supposed  to  bear  a  direct  etiological 
relationship  to  tuberculosis,  but  nothing  definite  was  known  on  the 
subject  until  the  father  of  modern  bacteriolog}",  Robert  Koch,  in  1882, 
announced  to  the  profession  his  great  discovery.  He  had  found  and 
demonstrated  the  true  and  essential  cause  of  tuberculosis,  the  bacillus 
of  tuberculosis,  and,  in  his  first  publication,  brought  such  convincing- 
proof  of  the  correctness  of  his  claim  that,  with  few  exceptions,  it 
brought  conviction  even  to  the  minds  of  the  most  skeptical.  He  had 
not  only  found  the  bacillus,  but  showed  that  it  was  present  in  all  tuber- 
cular lesions.  He  had  isolated  and  cultivated  the  bacillus  from  tuber- 
cular tissue  ;  and,  finall}',  he  had  furnished  the  crucial  test — had  produced 
tuberculosis,  artificiall}',  in  animals  bj'^  inoculation  with  pure  cultures. 

A  number  of  pathologists  wlio  inoculated  animals  with  non-tubercu- 
lar material  claimed  that  they  had  produced  patiiological  conditions 
analogous  to  those  found  in  animals  which  had  been  infected  with  the 
virus  of  tuberculosis.  Fragments  of  sponge  implanted  in  the  abdominal 
cavity  produce  a  condition  which  resembles  tubercular  inflammation,  and 
it  has  been  asserted  that  powdered  glass  has  a  similar  property.  Sehot- 
telins.  Wargunin,  Weichselbaum,  and  Martin  have  emploAcd  various 
substances  b}-  wa}'  of  experiment,  such  as  powdered  cheese,  brain- 
substance,  h'copodium-seed,  Cayenne  pepper,  and  pulverized  cantharides. 
They  caused  these  to  be  inhaled  in  the  form  of  a  fine  spray,  with  the 
result  that  the}'  were  almost  invariably  able  to  produce,  in  different  ani- 
mals, an  eruption  of  nodules  in  the  lung  and  sometimes  in  other  organs. 


■122  PRINCIPLES   OF    SURGERY. 

With  Liaiburger  cheese  Weichselbaum  produced  an  eruption  in  the  lungs 
and  kidneys  of  dogs,  after  fifteen  inhalations  during  seventeen  days, 
which,  liistologicall}',  could  not  be  distinguished  from  the  products  of 
genuine  tuberculosis.  Further  ex})erimentation  soon  showed  that  these 
were  instances  of  pseudo-tuberculosis  ;  tluit,  while  the  gross  appearances 
of  the  lesions  resembled  true  tuberculosis,  inoculations  with  this  material 
never  reproduced  the  disease,  while  inoculations  with  tubercular  tissue 
could  be  doue  through  a  series  of  animals  without  impairing  the  potency 
of  the  virus  or  varying  the  constancy  of  the  results.  Koch's  discovery 
did  not  lead  to  such  energetic  search  for  the  bacillus  of  tuberculosis 
among  surgeons  as  physicians,  because,  as  Konig  asserts,  the  symptoms 
and  signs  of  the  tuberculous  affections  coming  under  the  observation  of 
surgeons  are  so  characteristic  that,  for  practical  purposes,  a  correct  diag- 
nosis could  be  made  in  the  majority  of  cases  without  a  knowledge  of 
their  microbic  nature  and  the  improved  methods  for  making  a  positive 
diagnosis  derived  therefrom.  Koch  himself,  in  the  publication  above 
referred  to,  demonstrated  the  presence  of  the  bacillus  in  lupus,  the  so- 
called  scrofulous  glands,  tubercular  joints,  etc.  He  called  attention  to 
the  fact  that  in  these  affections  the  bacillus  can  be  constantly  found  in 
giant  cells  and  between  the  epithelioid  cells,  while  it  is  more  difficult  to 
find  it  in  chees}-  products,  unless  caseation  has  taken  place  quite  rapidl}-. 

Koch  examined  19  cases  of  miliary  tuberculosis,  in  which  bacilli 
were  found  in  every  nodule ;  29  cases  of  phthisis,  in  every  one  of  which 
bacilli  were  found  most  numerous,  with  the  exception  of  the  sputum,  in 
recent  caseous  foci  and  in  the  walls  of  cavities  undergoing  speedy  de- 
struction. He  also  found  them  constantly  in  tuberculous  ulcers  of  the 
tongue,  tuberculous  pyelo-nephritis,  and  tuberculosis  of  the  uterus  and 
testicles  ;  also  in  21  cases  of  tuberculosis  of  Ij^mphatic  glands.  Further, 
in  13  cases  of  tuberculosis  of  joints  and  in  10  cases  of  tuberculosis  of 
bone  ;  in  4  cases  of  lupus,  in  which  only  a  single  bacillus  could  be  seen 
in  the  giant  cells  ;  in  17  cases  of  Ferlsucht  in  cattle.  Finally,  in  animals 
inoculated  with  tubercular  virus  :  2*73  guinea-pigs,  105  rabbits,  44  field- 
mice,  28  white  mice,  19  rats,  13  cats,  besides  dogs,  chickens,  pigeons, 
etc.  Examinations  of  sputa  and  organs  in  various  other  non-tubercular 
aflTections  for  bacilli  resulted,  without  exception,  negatively. 

Weichselbaum,  Meisels,  and  Lustig  found  tubercle  bacilli  in  the 
blood  in  cases  of  acute  miliary  tuberculosis,  both  during  life  and  after 
death.  Schuchardt  and  Krause  examined  40  cases  of  tuberculosis  of 
bones,  joints,  tendon-sheatlis,  and  the  skin  in  Volkmann's  clinic,  and 
never  failed  in  finding  bacilli,  although  in  some  specimens  careful  and 
prolonged  search  had  to  be  made. 

Schlegtendal  examined  520  specimens  of  pus  from  tuberculous  sup- 


DESCRIPTION    OF    BACILLUS   TUBERCULOSIS.  423 

purations,  and  found  bacilli  present  in  about  75  per  cent,  of  the  cases. 
Mogling  found  the  bacillus  never  absent  in  tuberculous  pus  from  53 
patients.  The  literature  on  the  etiological  relation  existing  between  tlie 
bacillus  of  tuberculosis  and  the  atfections  of  the  skin,  glands,  bones,  and 
joints,  which  have  heretofore  been  grouped  under  the  head  of  scrofula, 
is  immense ;  but  the  foregoing  quotations  will  suffice  to  show  the  regu- 
larity with  which  the  bacillus  can  be  found  in  the  tissues  of  the  so-calle-d 
scrofulous  affections,  as  well  as  in  all  recognized  clinical  forms  of 
tuberculosis. 

DESCRIPTION    OF    BACILLUS   TUBERCULOSIS. 

The  tubercle  bacillus,  with  the  exception  of  the  bacillus  of  septi- 
caemia in  mice,  is  the  smallest  of  the  known  bacilli.  The  length  of  each 
rod  varies  from  one-fourth  to  three-fourths  of  the  diameter  of  a  red 
blood-corpuscle.  The  thickness  corresponds  to  that  of  the  bacillus  of 
sepsis  in  mice.  The  rods  are  either  straight  or,  what 
is  more  common,  bent  or  curved  near  the  centre. 

In  cultures  and  in  the  tissues  they  occur  singly, 
in  pairs,  or  in  bundles.  In  a  state  of  fructification 
the  bacilli  contain  from  two  to  six  spores.  In  stained 
rods  the  spores  appear  as  clear,  minute,  ovate  spaces, 
:is  the}'  are  not  affected  b}^  the  coloring  material.  BAciLLT^'coNTAmiNG 
In  some  bacilli  the  spores  form  slight  projections  on  ^xochf  ^'^^^^  A*^-"*- 
the  sides  of  the  rod.  Reproduction  bj-  spore  for- 
mation also  takes  place  in  the  tissues  within  the  animal  body.  In 
badly-stained  specimens,  and  on  superficial  examination,  the  spores  im- 
part to  the  bacillus  the  appearance  of  a  chain  coccus;  but,  examined 
closely,  it  is  seen  that  the  protoplasm  of  the  bacillus  is  continuous,  and 
the  apparent  interruptions  are  due  to  the  presence  of  the  spores.  The 
bacilli  of  tul)erculosis  are  non-motile,  and  consequently  possess  no  power 
of  locomotion,  and  cannot  penetrate  into  the  tissues  without  assistance. 
In  the  tissues  they  are  found  in  the  interior  of  giant  cells  and  within 
and  between  epithelioid  cells.  They  are  constantly  found  in  places  where 
the  tuberculous  process  is  commencing  or  actively  progressing.  In  the 
beginning  they  are  isolated  and  in  the  interior  of  cells  ;  later,  they  be- 
come more  abundant  and  form  groui)s.  In  cheesy  deposits  they  are 
either  entirely  absent  or  few  in  number.  The  virulence  of  caseous 
material  is  due  mostly  to  the  presence  of  spores,  which  may  remain  in  a 
latent  condition  and  yet  retain  their  power  of  reproduction  under  more 
favorable  conditions  for  an  indefinite  period  of  time.  As  soon  as  giant 
cells  appear,  they  contain  bacilli  in  their  interior,  as  a  rule.  In  some 
giant  cells  only  one  bacillus  can  be  found,  and  then  it  occupies  a  part  of 
the  cell  which  contains  uo  nuclei. 


/ 


42 J:  PRINCIPLES    OF    SURGERY. 

In  giant  cells  with  numerous  bacilli  the  latter  arrange  themselves 
around  the  periphery  in  the  interior  of  the  cell,  while  the  centre  contains 
few  or  none. 

The  first  inoress  of  bacilli  into  the  diseased  tissues  probably  takes 


-^  1 


Fig.  93.— Giant  Cell  with  One  Tubercle  Bacillus.    Section  from 
Lupus  of  Skin.    700:1.    {Fluegge.) 

place  by  wandering  cells,  which  transport  the  non-motile  microbe.  In 
many  inoculation  experiments  such  bacilli-containing  cells  have  been 
found  in  the  blood  and  tissues. 


Fig.  94 —Giant  Cell.    Miliary  Tuberculosis.    700:1.    (Fluegge.) 

Staining. — The  peculiar  behavior  of  the  bacillus  of  tuberculosis  to 
different  staining  material  enabled  Koch  not  only  to  discover  this 
microbe,  but  also  to  differentiate  it  from  all  other  microbes.  While  the 
aniline  dyes  and  other  nuclear  staining  material  showed  no  micro-organ- 


DESCRIPTIOX    OF    BACILLUS    TUBERCULOSIS.  425 

isms  in  tubercular  products,  the  bacillus  came  plainly  into  view  if  a  small 
quantity  of  alkali  was  added  to  the  aniline  solution.  Later  experience 
proved  that  the  same  effect  is  produced  if,  instead  of  an  alkali,  anilin, 
tolnidin,  turpentine,  carbolic  acid,  or  ammonia  is  added.  All  of  these 
substances  aid  the  penetration  of  the  staining  fluid  into  the  bacillus. 
Of  especial  advantage  is  the  discover}-,  also  made  bv  Koch,  that  the 
staining  fluid  is  fixed  more  permanentl}'  l\y  treating  the  sections  stained 
with  alkaline  aniline  d^-es  with  nitric  or  muriatic  acid,  a  procedure  which 
removed  the  staining  from  the  cells,  nuclei,  and  all  other  bacteria,  while 
the  tubercle  bacillus  alone  remains  ,_<r«<lj!\,_<,  i        "■«>>. 

stained.    The  preparation  is  further         \V  ^     #  \if/^^^^    *  /'N.\ 
completed  bv  staining  once  with  one       V      ^fe^^i    M        /Ji     v\        ^ 
of  the  ordinary  aniline  d3'es,  which        r\         !  X^~"     j^  it\| 
stains  the  cells  and  nuclei  and  other       VTL 
bacteria,  so  that  the  tubercle  bacil-  ,// 2A   /\ 

lus,  for  instance,  appears  red,  the 


nuclei  and  other  bacteria  blue.  ^^^ 

Most  of  the  bacilli  in  Fig.  95         "^^^J 


contain  spores,  the  majority  of  them     ^^^^i--^??'^,'^"  ^^t^^X^^'r^'''^"'' c^''^'" 
i  '  J         J  Phthisical  Sputum.    Double  Sstain- 

slightly   curved   or   bent:    they  lie  ing,  after  ehklich's  method,  xiooo. 

^        J  >  J  (Baumgarten.) 

free, — that    is,     outside     the     cells. 

Where  they  appear  to  be  within  the  cells,  a  close  examination  shows  them 

to  be  either  upon  or  underneath  the  cells. 

For  section-staining  Ehrlich's  method  is  the  best: — 

Saturated  alcoholic  solution  of  methyl-violet  or  fuchsin,    .  11  parts. 

Aniline  water, 100    " 

Absolute  alcohol, 10     " 

Sections  are  left  for  twelve  hours  in  this  solution.  Treat  the  speci- 
mens with  l-to-3  solution  of  nitric  acid  a  few  seconds  ;  wash  in  alcohol 
(60  per  cent.)  for  a  few  minutes;  after-stain  with  diluted  solution  of 
vesuvin  or  methylene-blue  for  a  few  minutes;  wash  again  in  60-per-cent. 
alcohol ;  delndrate  in  absolute  alcohol ;  clear  with  cedar-oil ;  mount  in 
Canada  balsam. 

The  examination  of  fluids  for  bacilli  can  be  done  rapidl}'  and  most 
satisfactorily  by  Gibbes'  method  : — 

GIBBES'    MAGENTA    SOLUTION. 

Magenta, 2  parts. 

Aniline  oil, 3    " 

Alcohol  (specific  gravitj- 0.830), 20     " 

Distiller)  water, 20    " 

Stain  cover-glass  preparations  in  this  solution  for  fifteen  or  twentj' 
minutes  ;  wash  in  l-to-3  solution  of  nitric  acid  until  the  color  is  removed  ; 


4*26  PKINCIPLES   UF    SURGERY. 

rinse  in  distilled  water ;  after-stain  with  inetli^'lcne-blue,  methyl-green, 
iodine-green,  or  a  watery  solution  of  cr^^soidin,  live  minutes;  wash  in 
distilled  water  until  no  more  color  comes  away;  transfer  to  absolute 
alcohol  fur  five  minutes;  dr}-,  and  preserve  in  Canada  balsam. 

Cultivation. — The  best  culture  medium  for  the  bacillus  of  tubercu- 
losis is  solid,  sterilized  blood-serum  of  the  cow  or  sheep,  with  or  without 
the  addition  of  gelatin,  at  a  temperature  of  37°  to  38°  C.  (98.6°  to 
100.4°  F.).  The  bacillus  grows  very  slowly,  and  only  between  the  tem- 
peratures of  30°  and  41°  C.  (86°  and  105.8°  F.).  In  about  a  week  or 
ten  days  the  culture  appears  as  little,  whitish  or  yellowish  scales  and 
grains.  Cultivations  can  also  be  made  in  a  glass  capsule  or  solid  blood- 
serum,  and  the  api)earance  of  the  growth  studied  under  the  microscope. 
The  scales  or  pellicles  are  then  seen  to  be  made  up  of  colonies  of  a 
perfectly  characteristic  appearance.  The  growth  ceases  after  three  or 
four  weeks.  The  blood-serum  is  not  liquefied  unless  putrefactive  bacteria 
contaminate  the  culture.  Frankel  figures,  in  his  "  Atlas  der  Bacterien- 
kunde^^^  a  luxuriant  culture  of  the  bacillus  of  tuberculosis  upon  glycerin- 
agar. 

Nocard  and  Roux  have  found  that  coagulated  blood-serum  is 
improved  for  the  growth  of  the  bacillus  by  adding  peptone,  soda,  and 
sugar.  A  further  addition  of  6  to  8  per  cent,  of  glycerin  favors  the 
growth  of  tlie  bacillus  still  more,  while,  at  the  same  time,  it  prevents  the 
formation  of  a  dry  crust  upon  the  culture  medium,  which  otherwise 
forms  by  evaporation.  They  also  made  successful  cultivations  upon 
agar-agar  bouillon,  to  which  was  added  6  to  8  per  cent,  of  gl3'cerin,  kept 
at  a  temperature  of  39°  C.  (102.2°  F.). 

Koch  has  cultures  3  years  old  which  have  passed  through  40  genera- 
tions and  still  retain  their  virulence,  showing  plainly  the  longevity  and 
tenacity  of  the  bacillus  of  tuberculosis. 

INOCULATION    EXPERIMENTS. 

Long  before  the  discovery  of  the  bacillus  of  tuberculosis  by  Koch, 
genuine  tuberculosis  was  produced  artificially^  in  animals  by  inoculation 
with  the  products  of  tubercular  inflammation.  Hueter  inoculated  the 
anterior  chamber  of  the  eye  in  rabbits  with  lupus-tissue,  and  produced 
typical  tuberculosis  of  the  iris.  Schiiller  introduced  fragments  of  lupus- 
tissue  directly  into  the  veins  of  animals,  and  in  this  way  caused  pulmo- 
nar}'  tuberculosis.  Koch  produced  tuberculosis  in  animals  susceptible 
to  this  disease  by  implantation  of  tubercular  tissue  in  various  localities 
and  by  inoculation  with  pure  cultures,  the  experiments  yielding,  almost 
without  exception,  positive  results.  The  same  author  inoculated  the 
anterior  chamber  of  the  eyes  in  18  rabbits  from  5  cases  of  lupus,  and  in 


INOCULATION    EXPERIMENTS.  427 

all  of  them  tuberculosis  of  the  iris  was  produced,  and,  if  life  was  pro- 
longed for  a  sufficient  length  of  time,  was  followed  by  tuberculosis  of 
the  lymphatic  glands  of  the  neck,  lungs,  kidneys,  liver,  and  spleen. 
Similar  results  were  also  obtained  in  5  guinea-pigs.  Cornet  has  made 
numerous  experiments,  in  Koch's  laboratory,  on  animals,  to  ascertain 
the  inoculabilit}-  of  tuberculosis  through  abrasions  of  the  skin,  or  a  pure 
culture  of  tubercle  bacilli  is  applied  to  a  cutaneous  abrasion  ;  the  result 
in  viost,  if  not  all,  cases  is  a  local  tuberculosis  in  the  adjacent  lymphatic 
glands,  and,  later,  a  general  miliar}-  tuberculosis. 

The  same  author  made,  more  recentl}^  a  long  series  of  experiments 
on  dogs,  to  ascertain  the  dili'erent  avenues  through  which  tubercular  in- 
fection is  known  to  take  place.  Tubercular  sputum  and  pure  cultures 
inserted  into  the  lower  conjunctival  sac  in  healthy  dogs  produced  tissue 
hyperplasia  at  the  seat  of  inoculation,  and  was  followed  by  infection  of 
the  cervical  glands  on  the  corresponding  side.  Some  of  the  glands 
underwent  caseation,  and  the  presence  of  bacilli  could  be  demonstrated 
in  all  of  the  pathological  products.  lu  other  animals  the  tubercular 
material  was  introduced  into  the  nasal  cavity.  The  cervical  glands, 
especially  those  on  the  corresponding  side,  became  enlarged  and  caseated. 
Infection  through  the  mouth,  by  depositing  the  tubercular  material  in  a 
depression  made  with  a  blunt  instrument  between  the  canine  teeth,  re- 
sulted also  in  tuberculosis  of  the  glands  of  the  neck.  Infection  of  the 
external  meatus  of  the  ear,  without  creating  an  infection-atrium  intention- 
ally, was  followed  by  infection  of  the  lymphatic  glands  behind  the  ear 
and  along  the  neck  on  the  same  side.  Cutaneous  tuberculosis  in  the 
form  of  an  ulcerating  lupus  was  produced  by  shaving  the  skin  on  one 
side  of  the  nose  and  iiice,  and  scratching  it  Avith  a  finger-nail  infected 
with  a  pure  culture.  Injection  of  pure  cultures  into  the  healthy  vagina 
of  bitches  resulted  in  local  tuberculosis  and  secondary  infection  of  the 
inguinal  glands.  Inoculations  of  other  parts  were  followed  by  the  same 
train  of  SA'mptoms. — local  tuberculosis  at  the  seat  of  infection,  followed 
by  dissemination  of  the  process  along  the  course  of  lymphatic  channels. 
'IMie  lungs  were  found  aflected  only  in  two  of  the  animals.  These  ex- 
periments show  conclusivel.y  that  the  bacillus  of  tuberculosis,  introduced 
through  superficial  peripheral  infection-atria,  seeks  the  lymphatic  chan- 
nels, through  which  it  is  extensivel}^  disseminated  before  general  infec- 
tion takes  place.  Cornil  and  Leloir  implanted  lupus-tissue  into  the 
peritoneal  cavity  of  guinea-pigs,  and  in  5  cases  out  of  14  experi- 
ments produced  peritoneal  and  general  tuberculosis.  Pagenstecher 
and  Pfeifter  took  the  secretion  of  the  conjunctiva  from  patients  suffering 
from  lui)us  of  this  structure,  and  injected  it  into  the  anterior  chamber  of 
the  eye  in  rabbits.     After  five  to  six  weeks  nodules  could  be  seen  on  the 


428  PRINCIPLES   OF    SUKGKRY. 

surface  of  the  iris,  which,  on  exauuiuition,  were  found  to  be  in  every 
respect  identiciil  with  tuberculosis  of  tliis  organ.  Doutrelepont  inocu- 
lated the  peritoneal  cavity  in  50  guinea-pigs,  and  in  8  rabbits  the  anterior 
chamber  of  the  e^'c  with  the  same  material,  with  the  result  that  in  all  of 
the  animals  local  tuberculosis  was  produced  at  the  point  of  inoculation, 
and  in  3  of  the  guinea-jjigs  and  in  1  rabbit  the  local  disease  was  followed 
by  general  tuberculosis. 

Inoculations  with  material  from  so-called  scrofulous  glands  produce 
the  same  etfect  as  when  lupus-tissue  is  used,  and  we  are,  therefore,  forced 
to  conclude  that  these  glands  owe  their  existence  to  the  same  cause. 
Arloing  prepared  an  emulsion  from  a  scrofulous  (tubercular)  gland, 
caseous  in  its  centre,  which  was  taken  from  a  boy  aged  14.  This  was 
injected  beneath  tlie  skin  of  10  rabbits,  and  the  same  number  of  guinea- 
pigs.  Visceral  tuberculosis  developed  in  all  of  the  guinea-pigs,  but  the 
rabbits  remained  health}',  except  that  2  showed  yellow,  caseous  granula- 
tions at  the  seat  of  inoculation.  Some  glands  excised  from  the  neck  of 
a  3'oung  woman  produced  tuberculosis  both  in  rabbits  and  guinea-pigs. 
The  patient  died  three  weeks  after  the  operation  from  miliary  tubercu- 
losis. From  these  experiments  he  inferred  that  either  scrofula  and  tu- 
berculosis were  nearly  allied  affections,  but  caused  by  different  agents,  or 
they  were  derived  from  the  same  virus,  of  which  the  activity  was  modi- 
lied  in  the  scrofulous  form. 

That  the  number  of  bacilli  Injected  has  a  great  deal  to  do  with  the 
result  has  recently  been  satisfactorily  demonstrated  by  Bollinger.  He 
found  that  infectious  milk  from  a  tuberculous  cow,  which  produced  local 
tuberculosis  by  intra-peritoneal  injections,  lost  its  virulence  if  diluted 
from  1:40  to  1:100.  The  sputum  of  phthisical  patients  was  found  much 
mure  virulent,  and  had  not  lost  its  power  to  produce  tuberculosis  on 
being  diluted  1:100,000,  on  being  injected  into  the  abdominal  cavit}',  or 
the  subcutaneous  connective  tissue.  Feeding  experiments  with  sputum 
diluted  1:8  yielded  negative  results.  Pure  cultures  remained  virulent 
when  diluted  1:400,000.  All  the  experiments  proved  that  the  more  con- 
centrated the  material  and  the  greater  the  number  of  bacilli,  the  more 
rapid  and  intense  was  the  development  of  the  lesion  caused  by  the  injec- 
tion. It  was  estimated  that  about  820  bacilli  were  necessarj^  to  produce 
tuberculosis  in  guinea-pigs.  Intra-peritoneal  injections  did  not  always 
produce  peritoneal  tuberculosis,  and  in  cases  where  this  did  not  occur 
tlie  organs  aftected  Avere  the  lymphatic  glands,  spleen,  lungs,  liver,  kid- 
neys, and  genital  organs,  in  the  order  of  frequency  named,  showing  con- 
clusivel}^  that  localization  does  not  invariably  take  place  at  the  point  of 
primarj-  infection. 

Direct   intra-venous   infection    by  injections   of  pure  cultures,  sus- 


INOCULATION-TUBERCULOSIS    IN    MAN.  429 

pended  in  distilled  water,  is  the  most  eflfective  way  in  which  diffuse 
miliary  tuberculosis  can  be  artificially  produced  in  animals  with  unfail- 
ing certainty.  Koch  succeeded  also  in  producing  the  disease  in  rabbits, 
guinea-pigs,  rats,  and  white  mice,  by  inhalation.  A  pure  culture,  sus- 
pended in  distilled  water,  was  used  with  a  hand-spra^',  and  the  cages  in 
which  the  animals  were  kept  were  filled  with  the  infected  spray.  The 
animals  were  killed  after  twenty-eight  da3's,  and  all  of  them  showed 
unmistakable  signs  of  pulmonar}^  tuberculosis. 

INOCULATION-TUBERCULOSIS   IN    MAN. 

The  opinion  that  tubercle  is  capable  of  inoculation  was  held  by 
ancient  writers,  and  Laennec,  himself,  after  a  nick  from  a  saw  while 
making  a  necropsj-  on  a  phthisical  subject,  thought  that  he  witnessed  an 
example  of  inoculation  in  a  small  tubercle  in  the  skin,  but  twenty  3'ears 
afterward  this  distinguished  clinician  was  in  good  health,  though  finally 
he  died  of  phthisis. 

Schmidt  made  a  number  of  experiments  to  ascertain  the  effect  of 
inoculations  of  superficial  abrasions  of  the  skin  with  the  virus  of  tuber- 
culosis. In  guinea-pigs  he  made  abrasions  in  the  skin,  to  which  he 
applied  tubercular  material  and  covered  the  point  of  inoculation  with 
collodium.  All  of  his  experiments  failed  in  producing  tuberculosis, 
while  in  the  control  animals,  in  which  the  infectious  material  Mas  intro- 
duced into  the  subcutaneous  tissue,  or  into  the  peritoneal  cavity,  tuber- 
culosis developed  without  a  single  exception.  He  believes  that  the 
results  of  these  experiments  are  only  corroborative  of  the  assertion 
previously  made  b}'  Bollinger  and  Koch,  that  the  susceptibility  of  the 
cutis  for  tubercular  infection  is  slight.  A  sufficient  number  of  authen- 
ticated cases,  however,  have  been  reported  during  the  last  few  3'ears,  to 
prove  that  in  man  tuberculosis  is  not  infrequently  contracted  b}'  the 
absorption  of  tubercular  material  through  small  wounds  and  superficial 
abrasions  of  the  skin.  Yolkmann,  a  number  of  3'ears  ago,  made  the  state- 
ment that  tubercular  infection  never  takes  place  through  a  large  opera- 
tion wound,  or  at  the  site  of  severe  injuries,  but  that  localization  of  the 
bacillus  is  likely  to  take  place  in  parts  the  seat  of  very  slight  contusions, 
or  what  ma}-  appear  at  the  time  as  an  insignificant  injur}-,  He  explained 
this  by  assuming  that  the  active  tissue  changes  which  take  place  during 
the  process  of  regeneration  after  a  severe  trauma  prevent  the  infection. 

In  studying  the  cases  of  inoculation-tuberculosis,  which  will  be 
referred  to  below,  it  will  be  seen  that  the  infection-atrium  was  always 
caused  by  a  trivial  injur}-.  A  very  interesting  case  of  inoculation  tuber- 
culosis came  under  my  own  observation  during  the  last  year.  The 
patient  was  a  strung,  healthy  young  woman,  with  a  good  family  history, 


430  PRINCIPLES    OF    SURGERY. 

who  wfis  emplo3'ed  in  a  rag  establishment  in  sorting  rags.  Two  months 
before  she  came  under  my  care  she  noticed  a  small  sore  on  the  dorsal 
side  of  the  right  index  finger,  near  the  metacarpo-phalangeal  joint.  The 
place  ulcerated,  and  the  granulation  tissue  which  appeared  melted  rapidly 
awa}',  forming  a  deep  excavation,  which  had  the  extensor  tendon  for  its 
floor.  Two  weeks  later  a  nodule  appeared  in  the  course  of  the  l3-mphatic 
vessels,  near  the  elbow-joint,  over  the  anterior  aspect  of  the  arm,  which 
was  soon  followed  by  the  formation  of  three  other  nodules  between  this 
point  and  the  primary  seat  of  infection.  General  health  not  impaired  in 
the  least.  Jnllamed  foci  neither  painful  nor  tender  on  pressure ;  presented 
distinct  evidences  of  (luctuation.  All  the  foci  were  excised  and  presented 
the  characteristic  appearances  of  tul)ercular  tissue.  The  primary  focus, 
after  excision,  left  such  a  large  defect  that  it  was  found  impossible  to 
close  the  wound  by  suturing,  and  consequently  the  surface  was  covered 
with  Thiersch's  grafts  taken  from  the  arm.  Primary  union  of  all  the 
sutured  wounds  and  speedy,  definitive  healing  of  the  defect  at  the  primary 
seat  of  infection. 

There  can  be  no  doubt  whatever  that  in  this  case  infection  occurred 
through  a  small  wound  of  the  index  finger,  by  handling  contaminated 
rags,  which  was  followed  b}^  dissemination  of  the  bacilli  through  the 
lymphatic  vessels  in  direct  communication  with  the  primary  infection- 
atrium.  I  have  had  also  under  treatment  a  well-marked  case  of  exten- 
sive subcutaneous  tuberculosis  of  the  hand,  in  the  person  of  the  mother 
of  several  children  who  had  died  of  pulmonary  tuberculosis.  The 
disease  originated  near  the  tip  of  the  index  finger,  at  the  site  of  a  former 
abrasion,  in  which  a  papillomatous  swelling  formed.  This  ulcerated  and 
healed  partl}^,  when  the  disease  commenced  to  spread  along  the  subcu- 
taneous connective  tissue,  and  when  the  patient  came  under  my  observa- 
tion it  had  extended  almost  over  the  entire  dorsum  of  the  hand.  A 
number  of  fistulous  openings  existed,  which  discharged  dail}'  only  a  few 
drops  of  thin,  serous  pus.  The  subcutaneous  tissue  was  transformed 
into  a  mass  of  granulation  tissue,  which  was  removed  with  a  small  spoon 
through  multiple  incisions,  and  the  wound  surfaces  were  freely  iodo- 
formized.  The  process  of  repair  was  slow,  but  satisfactory.  Martin  du 
Magny  has  collected  the  clinical  material  of  cases  of  inoculation-tuber- 
culosis, and  in  his  comments  upon  the  cases  asserts  that  the  sputum  of 
phthisical  patients  and  animal  excretions  were  the  usual  carriers  of  the 
bacilli ;  consequently  the  affection  is  most  frequentl}^  met  with  among 
physicians,  nurses,  butchers,  and  teamsters.  The  external  appearances, 
manifested  at  the  point  of  inoculation,  consist  in  the  formation  of  a  red 
nodule  in  the  skin,  which  increases  slowly  in  size  and  forms  miliary 
abscesses,  in  which  papillomatous  proliferation  takes  place,  and  around 


INOCULATION-TUBERCULOSIS    IN    MAN.  431 

which  a  new  zone  of  infiltration  forms,  which  in  turn  again  suppurates 
and  becomes  papillomatous.  The  centre  heals  with  the  formation  of  a 
flat  cicatrix,  while  the  destructive  process  progresses  slowlx*  in  a 
peripheral  direction. 

Hanot  has  collected  6  cases,  1  of  which  came  under  his  own  observa- 
tion. In  this  case  the  patient  was  in  the  third  stage  of  phthisis,  and 
died  soon  after  from  a  tubercular  ulcer  on  the  arm  of  at  least  two  years' 
standing,  while  the  history  of  cough  only  dated  from  the  last  two 
montlis,  which  would  show  that  the  cutaneous  lesion  preceded  the  pul- 
monary', and  was  the  cause  of  the  phthisis.  In  the  cases  which  he 
collected  the  sources  of  inoculation  were  necropsies  on  tubercular 
patients,  handling  old  bones,  pricking  the  hand  with  a  fragment  of 
porcelain  from  the  broken  spittoon  used  by  a  phthisical  patient,  and 
in  4  of  the  cases  the  tubercular  character  of  the  cutaneous  lesion  was 
verified  by  finding  the  bacilli. 

Eiselsberg  has  observed  4  cases  of  inoculation-tuberculosis  dur- 
ing the  last  few  j'ears.  The  first  case  was  a  girl  16  j-ears  old,  in  whom 
the  disease  developed  in  the  track  of  a  perforation  of  the  lobe  of  the  ear 
made  preparatorj^  to  the  wearing  of  an  ear-ring,  and  which  was  kept  from 
closing  by  the  insertion  of  a  thread.  The  tubercular  product  appeared 
in  the  shape  of  a  hard  swelling  the  size  of  a  hazel-nut.  The  second  case 
was  a  young  man  who  injured  himself  with  the  point  of  a  knife  above  the 
external  epicondyle  of  the  humerus.  Eighteen  days  later  a  swelling,  the 
size  of  a  pea,  appeared  at  the  site  of  injurv,  with  an  ulcerated  surface 
covered  by  pale,  flabb}^  granulations.  In  the  axilla  of  the  same  side  one 
of  the  h'mphatic  glands  was  found  enlarged  to  the  size  of  a  hazel-nut. 
The  third  case  concerned  a  woman  50  years  of  age,  who  was  supposed 
to  have  infected  herself  b}^  washing  the  clothes  of  a  person  the  subject  of 
a  tubercular  abscess  of  the  spine,  and  who  with  her  fingers  scratched  an 
acne  pustule  on  her  face.  At  this  point,  six  to  eight  days  later,  a  pain- 
ful swelling,  the  size  of  a  pea,  formed,  which  subsequently  became  indu- 
rated, and  opened  spontaneously  in  six  weeks.  At  the  end  of  three 
months  the  place  of  inoculation  presented  an  ulcer  with  indurated  mar- 
gins. In  the  fourth  case  the  inoculation  followed  in  the  track  made  b}- 
the  needle  of  a  h^^podermic  syringe,  in  a  girl  20  years  of  age.  The 
swelling  which  appeared  opened  after  six  weeks,  and  a  small  quantity  of 
pus  was  discharged.  Four  months  subsequently  the  fistulous  opening 
communicated  with  an  abscess-cavit}',  the  size  of  a  silver  dollar,  lined  by 
a  wall  of  granulation  tissue.  In  all  of  these  cases  no  evidence  of  tuber- 
culosis could  be  detected  iu  any  of  the  internal  organs,  and  the  local  dis- 
ease could  be  traced  in  every  instance  to  some  antecedent  lesion,  through 
which  the  infection  had  evidently  taken  place.     The  diagnosis  in  all  cases 


432  PRINCIPLES    OF    SURGERY. 

w:i.s  bused  on  an  examination  of  the  granulation  tissue  for  the  bacillus 
of  tuberculosis,  which  was  always  found  present. 

Another  ease  of  tubercular  infection  through  ear-rings  is  related 
from  Vienna  in  a  girl,  14  years  of  age,  of  a  perfectly  healthy  family',  who 
wore  ear-rings  left  to  her  b}'  a  friend  who  had  died  of  pulmonary  tuber- 
culosis. Soon  ulcers  appeared  on  the  lobes  of  both  ears,  the  cervical 
glands  became  swollen,  and  percussion  and  auscultation  revealed  infil- 
tration of  the  apex  of  the  left  lung.  Tubercle  bacilli  were  found  in  the 
ulcers  and  sputa.  This  case  is  onl}'  another  instance  of  inoculation- 
tuberculosis,  where,  from  the  point  of  infection,  the  disease  extended 
along  the  lymphatic  sj^stem,  and,  finall}^  S3'stemic  infection  from  the 
entrance  of  bacilli  into  the  general  circulation. 

In  the  cases  of  inoculation-tuberculosis  cited  above,  infection 
occurred  through  some  slight  lesion,  puncture,  or  abrasion,  which  fur- 
nished the  necessar^^  infection-atrium  for  the  entrance  of  the  bacillus 
into  the  tissues,  but  a  number  of  cases  have  been  reported  by  reliable 
observers  where  infection  took  place  through  a  larger  wound  or  granula- 
tion surface.  Middeldorpf  reports  the  case  of  a  health}^  carpenter,  who 
opened  his  knee-joint  by  the  cut  of  an  ax,  and  dressed  the  wound  with  a 
soiled  handkerchief.  The  wound  healed  kindly,  but  later  the  joint  be- 
came swollen,  tender,  and  painful.  Resection  was  performed,  and  on 
examining  the  capsule  it  was  found  very  much  thickened.  In  the  gran- 
ulation tissue  tubercle  bacilli  were  found.  Wahl  amputated  the  arm  of 
a  boy  suffering  from  gangrene,  the  result  of  an  injury,  and  discharged 
the  patient  with  the  wound  completel}^  healed,  except  a  small  granula- 
tion surface  from  which  the  drainage-tube  had  been  removed.  At  first 
the  wound  was  dressed  by  a  girl  suffering  from  tuberculosis.  The  wound 
soon  showed  all  the  characteristic  appearances  of  fungous  disease,  and 
the  lymphatic  glands  became  infected  from  this  source.  I  have  seen  in 
numerous  instances  large  wounds  made  for  the  removal  of  tubercular 
glands  become  infected  a  week  or  two  after  the  operation,  after  the 
superficial  wound  had  apparently  healed.  In  such  cases  the  overlying 
cicatrix  is  subsequentl}^  completely  destroyed  by  the  granulations  under- 
neath. The  energetic  use  of  the  sharp  spoon  and  free  iodoformization 
are  the  only  resources  in  finall}'  eflTecting  the  healing  of  such  wounds. 
Konig  has  seen  16  cases  of  inoculation-tuberculosis,  following  operations 
for  tubercular  disease  of  bones  and  joints,  and  2  such  cases  have  been 
described  by  Kraske.  Czerny  reports  2  cases  in  which  tuberculosis  fol- 
lowed in  wounds  treated  by  Reverdin's  method  of  skin-grafting.  In 
both  instances  the  patients  were  healthy,  and  the  skin-transplantation 
was  made  during  the  treatment  of  extensive  burns.  The  skin  was 
taken  from  limbs  amputated  for  tubercular  affections.     In  both  cases 


HISTOLOGY    OF   TUBERCLE.  433 

tuberculosis  of  the  adjacent  joint  occurred,  and  in  1  of  them  tul)ereulosis 
of  the  granulating  surface.  A  number  of  cases  of  inoculation-tubercu- 
losis following  circumcision  are  on  record,  in  which  the  infection  often 
occurred  in  the  practice  of  orthodox  Jews,  Avho  performed  the  operation 
in  accordance  with  tlie  directions  laid  down  in  the  Mosaic  laws.  The 
loose  connective  tissue  of  the  prepuce,  richly  supplied  with  lymphatics, 
is  an  admirable  surface  for  al)sorption,  and,  when  infectious  material  is 
brought  in  contact  with  it,  furnishes  the  most  favorable  conditions  for 
the  production  of  local  lesions  and  the  transportation  of  microbes  along 
the  lymphatic  channels  to  more  distant  parts. 

Lehmann  has  observed  10  cases  of  inoculation-tuberculosis  in 
Jewish  boys,  caused  b}'  sucking  the  wound  after  ritual  circumcision 
b}^  a  phthisical  person.  Ten  da^^s  after  the  circumcision  the  wound 
became  the  seat  of  ulceration,  and  the  inguinal  glands  began  to  enlarge. 
Four  of  the  children  died  of  tubercular  meningitis,  and  3  died  after  a 
prolonged  illness  caused  bj'  multiple  tubercular  al)scesses.  Hofmokl  has 
reported  a  similar  case,  and  Weichselbaum  detected  the  bacillus  of 
tuberculosis  in  the  circumcision  wound. 

Elsenberg  has  described  3  cases  of  tubercular  infection  after  circum- 
cision. All  the  cases  were  infants,  and  the  disease  appeared  primarily  in 
the  w^ound  or  cicatrix,  and,  later,  in  the  inguinal  glands.  Local  treat- 
ment b}'  scraping  proved  successful.  The  diagnosis  was  corroborated 
1)3'  microscopical  examinations  of  the  granulation  tissue.  Willj'  Me^'er  re- 
lates a  case  in  which  circumcision  was  performed  according  to  the  rules 
of  the  Jewish  Church  eight  days  after  birth  b}'  an  old  man,  and  in 
which  four  weeks  after  the  ceremony  an  induration  appeared  at  the 
frenulum,  and  the  inguinal  glands  about  the  same  time  began  to  enlarge. 
S^'philis  was  suspected,  and  the  little  patient  was  put  on  a  specific  course 
of  treatment.  The  inguinal  glands  suppurated,  and  another  small  ab- 
scess formed  in  the  right  gluteal  region.  The  diseased  tissue  about  the 
glans  penis  was  then  excised.  Microscopical  examination  of  the  granu- 
lations revealed  the  presence  of  miliar}-  tubercles  and  bacilli  in  great 
abundance.  The  above  cases  furnish  abundant  and  convincing  proof  of 
tlie  possibility  of  the  transmission  of  tuberculosis  b}^  cutaneous  inocu- 
lation through  superficial  abrasions,  small  wounds,  and  granulating  sur- 
faces, and  this  subject  is  deserving  of  the  most  careful  attention  of 
surgeons  in  the  matter  of  prophylaxis,  diagnosis,  and  treatment. 

HISTOLOGY    OF    TUBERCLE. 

A  tubercle-nodule  is  an  aggregation  of  cells  primarily  invisible  to 
the  naked  e^ye,  tlie  product  of  a  minute  focus  of  inflammation,  caused  by 
the  presence  of  the  essential  cause  of  tuberculosis.     When  the  nodule 


434  PRINCIPLES   OF   SURGERY. 

becomes  so  large  that  it  can  be  recognized  without  the  aid  of  the  micro- 
scope, it  alread}'^  consists  of  a  confluence  of  a  number  of  minute  micro- 
scopic nodules,  Lfennec  described  four  varieties  of  tubercle  :  1.  Miliary 
tubercle,  where  the  visible  product  of  tubercular  inflammation  appears 
as  nodules  the  size  of  a  millet-seed,  of  a  gra^ash  color,  and  usually 
arranged  in  groups.  2.  Crude  tubercle,  where  the  miliary  nodules  have 
become  confluent  and  have  undergone  caseous  degeneration.  3.  Granular 
tubercle,  where  the  nodules  are  extremely'  small,  nearly  the  size  of  a 
millet-seed,  and  scattered  uniformly  through  a  whole  organ.  They  are 
not  arranged  in  groups  and  have  no  tendency  to  become  confluent.  In 
the  centre  thej'  become  transformed  into  yellow  tubercle.  4.  Enc3'sted 
tubercles,  or  such  as  are  constituted  of  a  hard  mass  of  crude  tubercle  in 
the  centre  surrounded  by  a  firm  fibrous  capsule.  These  varieties  only 
represent  ditterent  phases  of  the  same  process  and  different  stages  of 
inflammation  produced  by  the  same  cause.  The  anatomico-pathological 
basis  of  tubercle  was  created  by  Vircliow,  and  has  been  firmly  established 
through  the  laborious  researches  of  Langhans,  Wagner,  Klebs,  Schuep- 
pel,  Rindfleisch,  Koester,  Friedlander,  Fox,  Baumgarten,  and  many  others. 
The  specific-cell  theory  has  had  many  able  advocates,  and  has  been  the 
subject  of  many  animated  discussions,  but  it  has  at  last  been  abandoned 
as  fallacious  and  unscientific.     There  are  no  specific  tubercle-cells. 

Lebert's  tubercle-corpuscle  is  a  thing  of  the  past,  and  is  only  re- 
ferred to  as  a  landmark  in  the  history  of  tuberculosis.  Reinhart  showed 
that  these  cells,  which  were  regarded  by  Lebert  as  characteristic  and 
pathognomonic  of  tubercle,  could  be  found  in  all  products  of  chronic 
inflammation,  and  their  presence  was  only  an  evidence  that  a  certain 
amount  of  inflammation  existed.  When  we  speak  of  a  tubercle,  we 
mean  a  nodule  or  granule,  which  is  composed  of  leucocytes  derived  from 
the  capillary  vessels  damaged  by  the  bacillus  of  tuberculosis,  or  new 
cells  derived  from  tissue  proliferation  of  pre-existing  cells  acted  upon  by 
the  same  cause.  The  anatomical  character  of  the  nodule  consists  not  in 
the  presence  of  any  particular  cell-element,  but  in  the  peculiar  arrange- 
ment of  the  cells;  and  this  feature  is  the  only  reliable  anatomical  guide 
in  making  a  diagnosis  by  the  use  of  the  microscope.  The  product  of 
tubercular  inflammation  occurs  either  in  the  form  of  submiliary,  micro- 
scopic granules,  visible  miliary  nodules,  or  a  cheesv  infiltration,  which 
may  occupy  an  entire  organ,  as  a  lymphatic  gland,  or  large,  isolated  foci, 
as  in  bone.  Every  tubercular  product  commences  as  submiliary  nodules, 
which,  when  tliey  become  confluent,  are  transformed  into  visible  gray 
miliar}'  nodules,  which  again  coalesce  after  the}'  have  undergone  caseous 
degeneration  from  cheesy  masses,  which  may  be  either  small  and  circum- 
scribed or  large  and  diffuse. 


HISTOGE>fESIS    OF    TUBERCLE.  435 

Yircliow  defines  tubercle  as  a  nodule  representing  a  heterogeneous 
growth,  a  product  originall}-  necessarilj'  of  a  cellular  nature,  taking  its 
starting-point  from  the  connective  tissue  or  from  other  mesoblastic  struc- 
ture, as  morrow,  fat,  or  bone.  He  asserts  that  the  microscopic  or  sub- 
miliarv  granule  contains  oil  of  the  essential  histological  elements  of 
tubercle,  and  by  aggregation  forni;^  the  ordinary  milinrv  nodiilo  of 
Lfennec.  When  the  nodules  become  confluent  the}-  ma}-  form  masses  the 
size  of  a  walnut,  surrounded  by  a  common  zone  of  embr3'onal  tissue. 
The  yellow  tubercle,  the  crude  tubercle  of  Lfennec,  is  a  more  advanced 
stage  of  the  gray,  the  histological  elements  of  the  latter  having  under- 
gone caseation. 

HISTOGENESIS    OF    TUBERCLE. 

Colberg  asserts  that  tubercles  in  the  lungs  originate  from  the 
nuclei  of  the  capillar}-  vessels  and  the  connective  tissue,  the  epithelial  cells 
lining  the  alveoli  never  being  primarily  affected.  Bastian  observed 
tubercle-nodules  upon  the  small  vessels  in  cases  of  basilar  meningitis, 
but  refers  their  origin  not  to  proliferation  of  the  nuclei  of  the  endo- 
thelial lining  of  the  vessels,  but  to  new  cells  springing  from  the  endo- 
thelial cells  of  the  perivascular  13-mphatic  sheaths  which  surround  the 
vessels  of  the  meninges  of  the  brain. 

Kuauff  demonstrated  the  lymphoid  character  of  the  adventitia  bj' 
examining  the  capillar}'  vessels  of  the  visceral  pleura  in  dogs  which  had 
been  exposed  for  a  long  time  to  an  atmosphere  impregnated  with  coal- 
dust.  He  found  the  pigment  lodged  in  small  masses  close  to  the  walls 
of  small  arteries  and  veins.  Examining  the  same  vessels  in  other  dogs 
not  thus  treated,  he  found  upon  the  outer  surface  of  the  adventitia 
opaque,  whitish-gray  nodules,  surrounded  by  round  and  oval  cells  con- 
taining nuclei,  also  lymph-corpuscles.  The  same  structures,  which  he 
named  lymph-nodules,  are  also  found  around  the  same  A'essels  of  the 
pleura  in  man,  and  Knaufi'  looks  upon  these  lymphoid  structures  as  the 
starting-point  of  tubercular  inflammation. 

Klebs  maintains  that  the  endothelial  cells  of  lymphatic  A'essels  are 
the  most  frequent  location  for  tlie  formation  of  the  primary  tubercle- 
nodule.  He  observed  that  in  eases  of  tubercular  ulceration  of  the  intes- 
tines the  peritoneum  is  reached  through  the  lymphatic  vessels.  Silver- 
stained  preparations  of  inoculation-tuberculosis  in  rabbits  showed  that 
the  most  recent  products  occurred  in  the  interior  of  the  lymphatic  vessels 
at  points  of  intersection.  In  some  places  the  nodules  extended  into  the 
tissues  between  the  lymphatic  vessels,  but  their  centre  always  corre- 
sponded to  the  location  of  a  lymphatic  vessel.  At  some  points  the 
nodules  were  seen  to  branch  out,  but  these  projections,  in  reality,  were 
within  the  lymphatic  vessels,  as  the  net-work  of  lymphatic   endothelia 


436  PRTNCTPLES    OF    SURGERY. 

could  be  seen  above  and  underneatli  the  tubercular  product.  Toward 
the  centre  of  the  nodule  no  endothelial  cells  could  be  distinguished,  and 
this  fact  led  him  to  the  belief  tlint  the  endothelial  cells  are  directly  con- 
cerned in  the  production  of  the  new  tissue.  In  the  mesentery  he  saw 
the  tubei'cles  ndhere  to  the  outer  wall  of  the  c:ii)illary  vessels,  and,  as 
the  spindle-shaped  cells  of  the  outer  coat  appeared  to  be  pushed  apart  by 
the  new  tissue,  he  regards  the  adventitia  as  a  genuine  lymphoid  struc- 
ture. Rindtleisch  traces  the  beginning  of  the  process  in  miliary  tuber- 
culosis of  the  lungs  to  a  proliferation  of  the  endothelia  and  the  external 
connective-tissue  la3'er  of  the  capillary  Ij'raphatic  vessels.  Edward 
Smith  believes  in  the  epithelial  origin  of  tubercle.  Manz  studied  the 
development  of  tubercle  in  the  choroid  in  patients  suffering  from  general 
miliary  tuberculosis.  So  constantly  does  this  disease  show  itself  in  this 
structure  that  von  Graefe,  Cohnheim,  Frankel,  and  Bouchut  recommend 
ophthalmoscopic  examination  as  a  diagnostic  measure  in  cases  of  sus- 
pected pulmonar}'  or  general  tuberculosis.  Manz  traces  the  commence- 
ment of  the  disease  in  the  choroid  to  cell-pullulation  in  the  tunica  adven- 
titia of  the  small  vessels.  The  process  is,  however,  not  limited  to  this 
structure  ;  the  non-pigmented  stroma-cells  ma}'  also  assist  in  furnishing 
material  for  the  new  product.  Bart,  on  the  other  hand,  asserts  that  the 
vessels,  in  cases  of  tuberculosis  of  the  choroid,  are  not  primarily 
affected  ;  according  to  his  observations,  the  process  depends  exclusivel}^ 
on  a  degeneration  of  the  stroma-cells,  as  the  remaining  tissue  did  not 
appear  affected. 

Cohnheim,  Ziegler,  and  others  maintain  that  the  leucocytes  furnish 
most  of  the  material  in  the  building  up  of  the  tubercle-nodule. 

Experiments  on  animals,  as  well  as  microscopic  examinations  of 
pathological  specimens,  have  suflicientl}'  demonstrated  the  fact  that  the 
tubercle-nodule  is  nothing  more  nor  less  than  a  circumscribed  inflamma- 
tory pi'oduct,  the  histological  elements  of  which  are  composed  of  new 
tissue,  formed  by  proliferation  of  fixed  tissue-cells  which  have  come  in 
contact  with  the  bacillus  of  tuberculosis  or  its  ptomaines.  The  specific 
pathogenic  effect  of  the  bacillus  consists  in  its  power  to  cause  a  chronic 
inflammation  of  the  tissues  in  which  it  has  localized  or  with  which  it  has 
been  brought  in  contact.  The  tissues  affected  are  the  cells  which  are 
nearest  the  essential  microbic  cause,  irrespective  of  their  embryological 
origin,  their  histological  structure,  or  physiological  function.  In  cases 
of  inoculation-tuberculosis  the  primar}^  nodule  develops  at  the  point  of 
insertion  of  the  virus  from  connective-tissue  proliferation,  and  from  here 
the  bacilli  enter  the  lymphatic  channels,  and  the  secondary  nodules  are 
composed  of  cells  derived  from  the  endothelial,  l3^mphoid,  and  connective- 
tissue  cells  which  compose  these  structures.     If  the  bacilli  are  injected 


HISTOLOGICAL    STRUCTURE    OF    TUBERCLE.  437 

directly  into  the  circulation  or  gain  entrance  into  the  ])lood-current  from 
some  tubercular  focus,  they  become  implanted  upon  the  wall  of  distant 
capillar}'  vessels,  and  the  nodule  which  forms  at  the  seat  of  implantation 
consists  of  cellular  elements  formed  b}'  the  tissues  of  the  vessel-wall. 
As  aoon,  however,  as  bacilli  reach  the  extra-vascular  tissues,  they,  in 
turn,  furnish  tlieir  part  of  the  material  for  the  further  growth  of  the 
nodule.  If  the  tubercle  bacillus  becomes  implanted  upon  a  mucous  sur- 
face, as  the  bladder,  intestines,  nose,  larynx,  uterus,  etc.,  if  such  surface 
is  susceptible  to  tubercular  infection,  the  epithelial  cells  take  an  earl}' 
and  active  part  in  the  inflammator}'  i)rocess.  From  the  manner  of  en- 
trance into  and  diffusion  tlirough  the  tissues,  it  is  apparent  that  the 
mesoblastic  tissues,  the  connective-tissue  and  endothelial  cells,  being  the 
first  to  become  infected,  furnish  the  greatest  amount  of  material  in  most 
tubercular  lesions;  but  all  tissues,  when  infected,  take  part  in  the  process. 

HISTOLOGICAL    STRUCTURE    OF    TUBERCLE. 

The  essential  histological  elements  which  make  up  a  primary  tubercle- 
nodule  are:  (a)  leucocytes;  (6)  giant  cells;  (c)  epithelioid  cells;  (d) 
reticulum. 

Leucocytes. — One  of  the  conA-incing  proofs  of  the  inflammatory 
nature  of  tuberculosis  is  the  presence  of  leucocytes  in  the  tubercle- 
nodule.  The  bacillus  of  tuberculosis  appears  to  exercise  only  a  mild 
pathogenic  effect  on  the  capillary  wall,  and  the  primar}'  inflammatory 
product  is  always  scanty.  As  the  colorless  blood-corpuscles  can  onl}' 
escape,  in  considerable  number,  through  inflamed  capillary  walls  which 
have  undergone  alteration  from  the  action  of  some  specific  microbic 
cause,  it  is  evident  that  its  migration  into  the  para-vascular  tissues,  where 
it  forms  a  part  of  the  tubercular  product,  can  onl}^  occur  after  such 
alteration  has  taken  place  from  the  action  of  the  bacillus  upon  the 
cement-substance  of  the  endothelial  lining  of  the  capillary  vessels.  The 
leucoc3'tes  are  found  scattered  among  the  other  cellular  elements,  and  are 
found  in  greatest  abundance  toward  the  periphery  of  the  nodule.  The 
leucocytes  invariably  undergo  degenerative  changes,  and  are  never  trans- 
formed into  other  forms  of  cells  found  in  the  tubercular  product.  The}^ 
have  been  described  as  lymphoid  corpuscles.  Although  constantly  pres- 
ent, they  are  most  numerous  when  the  process  is  acute. 

Giant  Cells. — A  great  deal  has  been  said  and  written  concerning  the 
origin  and  diagnostic  value  of  the  giant  cells  in  the  tubercle-nodule. 
The}^  resemble  the  giant  cells  found  in  some  forms  of  sarcoma,  and 
appear  to  be  simpl}'  certain  cells  which  have  outgrown  others  by  taking 
up  a  greater  amount  of  nourishment  in  the  shape  of  leucocytes  which 
have  undergone  fragmentation. 


438 


I'KINCIPLES    OF    SUliGEUY 


The  uianl  cells,  or,  ns  Klebs  calls  tliem,  macrocytes^  are  finely  gran- 
ular, and  contain  multiple  nuclei,  which  usually  occupy  the  periphery  of 
the  cell,  or  are  arranged  in  a  crescent  at  one  end.  In  tubercular  lesions 
artificially  produced  in  animals  the  giant  cells  contain  numerous  bacilli, 
which  occupy,  as  a  rule,  the  peripheral  zone  of  the  cells.  In  tuberculosis 
in  man  the  bacilli  in  these  cells  are  never  so  numerous,  and  as  central 
degeneration  of  the  cells  appears  they  disappear  in  this  portion  of  the 
cell,  while  some  may  still  be  found  in  the  periphery.  During  the  progress 
of  the  disease  the  giant  cell  becomes  more  and  more  fibrous  toward  the 
peripher}^  at  the  expense  of  the  protoplasmic  part  in  the  centre.  The 
protoplasm  evidently  is  transformed  into  or  secretes  the  fibrous  margin. 


^..^. 


Fig.  96.— Giant  Cell  fkom  Centre  of  Tubercle  ok  Luno.    x  450.    {Hamilton.) 

A,  granular  protoplasmic  centre ;  B,  peripheral  more-formed  part  ;  C,  crescent  of  nuclei ; 
D,  endothelium-like  cells ;  E,  two  vacuoles  within  the  giant  cell. 

If  caseation  does  not  take  place  the  bacilli  disappear,  and  the  whole  cell 
mass,  including  the  giant  cells,  is  converted  into  a  cicatricial  mass. 

The  first  evidences  of  degeneration  appear  in  the  centre  of  the  giant 
cells,  and,  according  to  Weigert,  the}'  consist  of  strnctund  and  chemical 
chano-es  which  are  indicative  of  coagulation  necrosis. 

In  a  recent  tubercle-nodule  the  giant  cells  occupy  the  central  por- 
tion, around  which  the  epithelioid  cells  and  leucocytes  are  arranged. 
The  vacuoles  are  necrotic  foci  within  the  cells. 

The  giant  cell  found  in  tubercular  tissue  has  its  prototype  in 
normal  tissue.  Giant  cells  were  first  discovered  in  normal  tissue  (mar- 
row of  bone)  by  Robin,  who  called  them  myeloplaques.  They  were  sub- 
sequently accurately  described  b}'  Virchow.    In  a  normal  condition  they 


HISTOLOGICAL    STRUCTURE    OF    TUBERCLE.  439 

are  constantly  found  in  bone  and  the  placenta.  They  are  also  found 
occasionally  in  fat-tissue,  especially  in  cases  of  rapid  emaciation.  Kun- 
drat  has  found  them  in  iuflamed  serous  membranes,  and  Strieker  and 
Heitzmann  iu  the  inflamed  cornea.  They  are  always  found  around  for- 
eign bodies,  becoming  encysted  in  the  tissues.  Friedlander  found  them 
present  in  the  aveoli  of  the  lungs  in  cases  of  chronic  pneumonia. 

Heubner  found  giant  cells  in  endarteritis,  Baumgarten  in  gummata, 
Buhl  and  Jacobson  in  granulating  wounds,  and  finall}-  Jdhne  and  Pflug 
in  actinomycotic  foci.  The  histological  source  of  these  cells  in  tuber- 
cular affections  has  been  traced  to  epithelial  cells  by  Zielonko  and 
Weigert ;  to  endothelial  cells  by  Kundrat,  Klebs,  Herrenkohl,  and  Zie- 
lonko ;  to  connective  tissue  or  endothelial  cells  by  Yirchow,  Fleming, 
and  Ziegler.  Schueppel  and  Rindfleisch  believe  that  they  invariably 
originate  within  blood-vessels  or  hmphatics,  where  these  authors  regard 
them  as  the  first  step  toward  the  development  of  tubercle-nodules. 
Ziegler  claims  to  have  seen  giant  cells  develop  from  white  blood-corpus- 
cles. Hering,  Aufrecht,  Woodward,  Schueller,  and  Treves  are  of  the 
opinion  that  what  appears  as  giant  cells  in  tubercular  tissue  are  not  cells, 
but  onl}-  represent  spaces  which  correspond  to  transverse  sections  of 
lymphatic  channels,  the  protoplasm  representing  the  coagulated  Ij-mph 
within  these  vessels,  and  what  appear  as  nuclei  being  enlarged,  swollen 
endothelial  cells.  Giant  cells  possess  amoeboid  movements,  and  by 
virtue  of  these  they  are  capable  of  taking  up  in  their  protoplasm  fine 
particles,  such  as  microbes,  pigment  material,  and  blood-corpuscles, 
which  have  undergone  fragmentation.  The  giant  cells  in  tubercular 
lesions  are  hyperplastic,  epithelial  cells,  and  consequently  are  derived 
from  the  same  histological  source  as  these. 

Epithelioid  Cells. — Cells  intermediate  in  size  between  the  giant  cells 
and  the  leucocytes  are  found  in  everj-  tubercle-nodule  in  which  the  cells 
liave  not  been  destroj'ed  b}'  caseation.  These  cells  were  first  described 
b}-  Rindfleisch,  and  were  called  b}'  him  epithelioid  cells  from  their  struc- 
tural resemblance  to  epithelial  cells.     Klebs  calls  them  platycyies. 

They  are  about  two  or  three  times  larger  than  a  white  blood- 
corpuscle,  and  in  shape  they  are  eitlier  round  or  somewhat  elongated. 
In  structure  they  are  finely  granular,  and  contain  one  large  and  often  a 
number  of  small  nuclei.  Thej' form  the  bulk  of  all  recent  nodules,  are 
scattered  between  the  giant  cells,  and  are  often  arranged  in  layers  around 
them.  The  histological  source  for  these  cells  was  supposed  to  be  the 
leucocyte  b}-  Schueppel,  Ziegler,  and  Treves;  the  endothelial  cells  of  the 
Ijmph-spaces  by  Aufrecht,  Hering,  and  Woodward  ;  the  endothelial  cells 
of  the  blood-vessels  and  lymphatics  or  connective-tissue  cells  by  Rind- 
fleisch and  nearlv  all  of  the  modern  authors.      The  endothelioid  cells 


440  PRINCIl'LES    UF    SI  UGEKV. 

represent  the  embryonal  colls,  the  product  of  proliferation  from  any  of 
the  fixed  tissue-cells  in  a  tubercular  lesion,  and  they  remain  as  such  until 
they  are  destroyed  by  degenerative  changes  from  the  continued  action 
upon  them  of  the  bacillus  of  tuberculosis  or  its  ptomaines,  or  until,  on 
cessation  of  the  primary  cause,  they  are  transformed  into  tissue  of 
greater  durnbility. 

Reticulum. — Schueppel  lirst  called  attention  to  tlie  reticulated 
structure  of  tubercle  by  his  description  of  the  reticular  arningement 
within  tubercles  of  lymphatic  glands. 

The  reticulum,  according  to  most  authors,  (ionsists  of  the  pre- 
existing connective  tissue  pushed  asunder  by  the  new  cells.  According 
to  Wagner,  Schueppel,  Brodowski,  Tliaon,  and   Ziegler,  it  is  made  up  of 


Fig.  97 Section  from  Mucous  Membrane  of  Pharynx,  showing  Epithelioid  Cells 

WITH  A  FEW  Small  Giant  Cells.    X  350.    (Birch-Hirschfeld.) 

protoplasm.  Buhl  taught  that  the  giant  and  e[)itiielioid  cells  secrete  a 
substance  at  their  periphery  which,  on  becoming  firm,  is  formed  into  a 
structure  resembling  connective  tissue.  According  to  his  researches 
only  the  marginal  zone  is  supplied  with  loose,  read^'-formed,  connective 
tissue  of  the  organ.  Wahlberg  maintained  that  the  principal  reticulum 
consists  of  protoplasm  which  is  traversed  by  a  net-work  of  connective 
tissue.  The  reticulum  is  always  more  marked  in  the  periphery  of  the 
tubercle-nodule,  where,  from  pressure,  it  is  condensed  into  a  fibrous 
capsule  (Fig.  98,  C). 

Arrangement  of  the  Cells  in  a  Recent  Tubercle-Nodule. — The  earliest 
evidence  of  the  formation  of  a  tubercle-nodule,  as  witnessed  under  the 
microscope,  is  the  appearance  of  small  cells  which  resemble  ordinary 


HISTOLOGICAL    STKUCTUKE    OF    TUBERCLE. 


Ul 


embryonal  cells,  which  are  the  product  of  tissue  proliferation  from  a 
mesoblastic  matrix,  usually  the  connective  tissue,  and  its  embryological 
and  histological  prototype,  the  endothelial  cells  of  blood-vessels  and 
lymphatics.  From  these  cells  the  epithelioid  and  giant  cells  are,  later, 
developed.  Some  of  the  central  cells,  b^-  appropriation  of  a  superabund- 
ance of  food  furnished  by  leucocytes  in  a  state  of  fragmentation,  become 
hj'perplastic,  and  are  transfunned  into  giant  cells  ;    these  occup}-  the 


//I  w 

Jjj: 


Fig.  98.— Fully-Developed  RsTicrLAR  Tcbeecle  of  Lvng.    x  4.50.    (Uamilton.) 

A,  A,  A,  giant  cells ;  B,  vacuole  in  one  of  these :  C.  peripheral  capsule  of  fibrous  tissue ;  D.  reticulum 
of  the  tubercle  :  E,  large  enilothelium-like  cells  lying  on  the  reticulum  and  within  its  meslies  ;  F,  smaller 
"  lymphoid  "  cells  occupying  the  same  situation  ;  G,  peripheral  fibrous-looking  border  of  the  giant  cells. 

centre  of  the  nodule.  Around  these  cells  the  smaller  or  epithelioid  cells 
arrange  themselves,  and  between  them  and  in  the  periphery  of  the  nodule 
are  found  the  smallest  cells, — the  leucocytes. 

Gaule  and  Tizzoni  distinguish  three  zones  in  a  tubercle:  (1)  an 
external,  composed  of  small  round  cells;  (2)  a  leper,  epithelial,  or 
middle  zone,  containing  the  reticulum  ;  (3)  a  central  space  containing  a 
giant  cell.  The  structure  of  a  tubercle  is  not  always  typical,  and  hence 
the  division  into  zones  is  based  more  on  theoretical  "rounds  than  actual 


442  PRIXCIPLES   OF    SURGERY. 

observation.  The  giant  cell  is  not  an  essential  histological  element  of 
tubercle,  but  an  accidental  product.  In  some  tubercles  giant  cells  can- 
not  be  found,  wliile  in  others  they  are  numerous.  Giant  cells  can  only 
develop  I'rom  I'pithelioid  cells  if  tlie  local  conditions  are  favorable  for 
hypernutrition  ;  tiiat  is,  if  the  leucocytes  in  a  condition  of  fragmentation 
are  witliin  their  reacli.  If  they  are  present  tliey  always  mark  the  loca- 
tion  of  tlie  starting-point  of  the  tultercuiar  infection,  as  only  the  older 
epithelioid  cells  undergo  this  change.  Tlie  number  and  size  of  the 
epithelioid  cells  are  also  subject  to  great  variation,  and  are  modified  by 
the  nutritive  conditions  within  and  in  the  immediate  vicinity  of  the 
nodule.  If  cell  proliferation  is  active  the  epithelioid  cells  appear  densely 
packed  in  the  reticulum,  nutrition  is  greatly  impaired,  and  the  new 
cells  undergo  degenerative  changes  before  they  attain  their  average  size. 
The  leucocytes  are  scattered  among  the  giant  and  epithelioid  cells,  and, 
as  they  reach  the  part  through  the  inflamed  wall  of  the  capillaries  in  the 
immediate  vicinity,  they  are  most  numerous  in  the  periphery  of  the 
nodule  and  along  the  course  of  the  atfected  vessels. 

GROWTH    OF   THE    TUBERCLE-NODULES. 

The  typical  tubercle-nodule  is  microscopic  in  size.  Tlie  growth  of 
the  swelling  depends  on  the  formation  of  new  tissue,  migration  of  leuco- 
cytes, and  confluence  of  nodules  into  larger  masses.  The  bacillus  of 
tuberculosis,  when  brought  in  contact  with  fixed  tissue-cells  susceptible 
to  its  pathogenic  action,  incites  tissue  proliferation,  which  always  takes 
yjlace  bj'  karyokinesis.  Baumgarten's  investigations  leave  no  doubt  that 
phatycytes  constitute  the  entire  mass  of  the  forming  tubercle.  He  has 
also  observed  karyokinetic  figures  in  tubercular  tissue  in  cells  derived 
from  the  connective  tissue,  endothelia,  and  epithelia.  The  tubercle 
bacilli  are  found  in  the  interior  of  giant  and  epithelioid  cells  and  between 
them. 

Each  tubercle-nodule  increases  in  size  by  the  growth  of  new  cells 
from  pre-existing  tissue,  and  as  the  primary  cause,  the  bacillus  of 
tuberculosis,  multiplies  in  the  tissues,  bacilli  are  conveyed  into  the 
surrounding  tissues  by  leucocytes  or  the  plasma-current,  and  new  centres 
for  tubercle  formation  are  established,  which,  later,  become  confluent, 
forming  masses  of  considerable  size,  the  numei'ous  foci  of  caseation 
corresponding  to  the  centre  of  a  nodule.  The  growth  of  tubercle  is 
favored  by  local  and  general  conditions  which  diminish  tissue  resistance, 
while  retardation  takes  place  in  consequence  of  degenerative  changes  in 
tlie  cells  of  which  it  is  composed,  or,  if  the  cells  are  converted  into  tissue 
of  a  higher  type,  from  disappearance  or  suspension  of  activity  of  the 
primary  cause. 


PATHOLOGICAL    VARIETIES   OF    TUBERCLE.  443 

PATHOLOGICAL    VARIETIES   OF    TUBERCLE. 

Several  varieties  of  tubercle  have  been  described,  according  to  the 
histological  structure  of  tiie  tubercle  or  the  structure  or  condition  of  the 
cells  of  whicli  it  is  composed. 

Reticulated  Tubercle. — This  is  tlie  ordinary  form  of  tubercle  usually 
met  with,  and  tlie  most  important  anatomical  feature  is  the  presence  of 
a  well-detined  reticulum,  comi)osed  of  pre-existing  connective  tissue  and 
a  delicate  iiet-worli  of  brandling  giant  cells,  in  the  meshes  of  which  are 
found  the  epithelioid  cells  and  leucocytes. 

Fibrous  Tubercle. — In  contradistinction  to  the  reticulated  or 
lymphoid  tubercle,  a  few  years  ago  the  tibrous  tubercle  w-as  described, 
distinguished  by  its  pearl-like,  light-gray  appearance,  but  possessing  the 
same  inherent  tendency  to  caseation.  It  is  said  to  be  found  most  fre- 
quently in  dense,  librous  tissue,  and  quite  often  in  newl^'-formed  connective 
tissue.  Histologically  it  is  composed  of  nodules  of  dense  connective 
tissue,  the  cells  of  which  have  undergone  rapid  growth,  containing,  fre- 
quently, more  than  one  nucleus.  A  further  development  only  takes 
place  in  the  interior  of  the  nodule,  as  here  caseation  occurs,  the  caseous 
focus  being  surrounded  bj'^  a  firm  capsule  of  connective  tissue.  The 
description  of  fibrous  tubercle  by  Langhans  differs  materially  from  the 
above.  According  to  investigations  of  this  author,  the  fibrous  tubercle 
has  for  its  favorite  location  the  so-called  parenchymatous  organs,  as  the 
lungs,  liver,  spleen,  kidnej-s,  testicles,  epididymis,  and  brain.  The  larger 
nodules  are  composed  of  three  zones.  The  central  zone  consists  of  a 
few  connective-tissue  fibres,  free  oil-globules,  and  cells  in  a  condition  of 
fatt}'  infiltration.  The  middle  zone  is  composed  of  connective  tissue. 
As  the  cells  of  this  zone  are  not  numerous,  it  presents  the  appearance  of 
a  capsule ;  in  reality,  however,  it  is  not  a  capsule  in  the  proper  sense  of 
the  word,  but  a  matrix  of  tissue  proliferation,  from  which  the  central 
part  of  the  tubercle  is  the  oti'spring.  Both  Langhans  and  Schueppel, 
like  nearh'  all  of  the  modern  pathologists,  regard  fibrous  tubercle  not  as 
a  distinct  special  anatomical  form,  but  as  an  ordinar}^  tubercle  in  which 
the  epithelioid  cells  in  the  peripheral  zone  have  been  converted  into  con- 
nective tissue.  Fibrous  tubercle  differs  from  the  ordinary  cellular 
variety  onl>-  in  so  far  that  it  contains  a  larger  amount  of  connective 
tissue.  If  in  a  tubercle-nodule  at  the  time  the  young  cells  are  yet 
vigorous  the  primary  microbic  cause  ceases  to  act,  degenerative  changes 
fail  to  take  place  and  the  embryonal  cells  are  transformed  into  connec- 
tive tissue.  The  cicatricial  condition  starves  out  remaining  embryonal 
cells  ;  at  the  same  time  an  impermeable  wall  of  connective  tissue  is  thrown 
around  the  primary  depot  of  infection,  which  effectually  guards  against 
the  escape  of  active  bacilli  or  their  spores  into  the  surrounding  tissues. 


444  I'RINCirLlvS    OF    SURGf:RY. 

Hyaline  Tubercle. — Chimi  described  another  variety  of  tul)crcle — 
tlie  hyiiline  tubercle.  The  first  si)eeimen  in  which  lie  found  tiiis  variety 
was  taken  from  the  liver  of  a  tuberculous  child  4  years  of  age.  The 
nodules  in  the  brain,  lungs,  and  bronchial  glands  in  the  same  case  pre- 
sented the  ordinary  structure  of  lymphoid  tuljcrcle.  The  clear  hyaline 
structure  of  those  found  in  the  liver  gave  them  a  very  i)eculiar  appear- 
ance. The  clmuge  is  believed  to  be  due  to  a  hyaline  degeneration  of  the 
reticulum,  and  reseniltles  most  closely  the  hyaline  degeneration  of  the 
capillaries  of  the  brain.  Chiari  conjectures  that  it  may  be  regarded  as 
a  benign  change  opposed  to  caseation,  which  tends  to  infection.  Hyaline 
degeneration  of  any  pathological  product  must  now  be  considered  as 
one  of  the  earliest  phases  of  coagulation  necrosis,  and,  if  a  considerable 
area  of  the  nodule  undergo  this  change  rapidl}'  and  simultaneously, 
the  structures  will  present  a  hyaline  appearance  ;  but  if  the  hyaline 
product  continue  to  be  acted  upon  by  the  same  causes,  caseation  will 
follow,  and  the  hyaline  tubercle  becomes  a  chees}-  tubercle. 

CASEATION. 

The  gray  or  miliarj-  tubercle  is  transformed  into  the  yellow,  crude, 
or  cheesy  tubercle  hy  a  process  which  is  called  caseation,  or  tyrosis. 
The  exact  nature  of  this  process  remains  unknown.  The  cheesy 
material  is  composed  of  the  products  of  cell  necrosis.  Early  death  of 
cells  is  the  most  characteristic  pathological  feature  of  tul)ercle,  Avhich 
distinguishes  it  from  all  other  forms  of  chronic  inflamination.  Two 
causes  can  be  advanced  to  explain  this  peculiar  and  almost  pathogno- 
monic form  of  degeneration,  which  occurs,  almost  without  exception,  in 
every  tubercle  if  a  sufficient  length  of  time  has  elapsed  :  1.  Inadequate 
blood-supply.  2.  Specific  action  of  the  bacillus  of  tuberculosis  or  its 
ptomaines.  Caseation  alwa^'S  commences  in  the  centre  of  a  nodule, 
consequently  at  a  point  most  remote  from  the  vascular  supply,  and  in 
cells  Avhich  have  been  exposed  longest  to  the  deleterious  effect  of  the 
primary  microbic  cause.  Tubercle  is  a  non-vascular  product.  From 
causes  which,  as  j'et,  are  not  known,  the  tubercular  product  is  not 
supplied  with  new  blood-vessels.  The  angioblasts  are  transformed  into 
epithelioid  cells  that  have  lost  their  power  of  vessel  formation.  Nodules 
which  have  priinarilj^  an  intra-vascular  origin  are  rendered  avascular  by 
closure  of  the  vessel  from  intra-  and  peri-  vascular  cell  proliferation.  If 
the  primary  starting-point  is  outside  of  the  vessels,  the  rapidly  accumu- 
lating cells  exert  pressure  upon  the  surrounding  vessels,  and  thus 
diminish  the  1)lood-sn[)ply  to  the  part  affected.  The  new  cells  require 
an  adequate  blood-supply  for  their  further  development,  and  if  this  fail 
to  take  place,  as  is  the  case  in  eveiy  tubercular  product,  they  necessarily 


CASEATION.  445 

suffer  from  malnutrition,  and  undergo  degenerative  changes  at  an  early 
stage  of  their  existence.  A  deficient  blood-supply,  in  the  absence  of 
other  causes,  would  result  in  fatt}'  degeneration  of  the  new  vessels  ;  but 
caseation  is  something  different  from  ordinary-  fatty  degeneration,  and 
the  bacillus  of  tuberculosis,  or  its  ptomaines,  must  be  regarded  as  its 
immediate  and  essential  cause.  Caseation  is  preceded  by  coagulation 
necrosis,  which  is  one  of  the  results  of  the  specific  action  of  the  bacillus 
on  the  tissues.  The  coagulation  necrosis  commences  in  the  giant  cells, 
and  in  the  epithelioid  cells  in  the  centre  of  the  nodule,  and  caseation 
follows  as  soon  as  the  dead  cells  have  lost  their  histological  identity, 
and  appear  under  the  microscope  as  a  debris  in  which  no  distinct  cell 
forms  can  be  identified.  Caseation  is  attended  by  softening,  which  can 
be  readily  recognized  in  tubercular  masses  the  size  of  a  hazel-nut  to  that 
of  a  walnut,  composed  of  numerous  confluent  nodules  with  as  man}' 
caseating  foci. 

In  such  masses  the  small,  chees}-  cavities  become  confluent  and  form 
spaces  of  considerable  size.  Caseation  proceeds  from  the  centre  of  each 
nodule  toward  the  periphery,  layer  after  layer  of  epithelioid  cells  being 
destro^'cd  and  changed  into  cheesy  material.  The  part  of  a  tubercle- 
nodule  which  has  undergone  caseation  contains  few,  or  no,  bacilli,  and 
3^et  inoculation  experiments  show  it  to  be  highly  infectious.  The  cheesy 
material  does  not  furnish  the  proper  nutrient  material  for  the  growth 
and  development  of  the  bacillus,  which  dies  from  starvation,  while  the 
spores,  being  more  durable  and  possessing  greater  power  of  resistance, 
remain  in  an  active  condition  for  an  indefinite  period  of  time  in  the  dead 
material,  and  it  is  due  to  their  presence  that  infection  takes  place  from 
cheesy  foci,  and  that  successful  inoculations  can  be  made  with  cheesy 
material.  While  the  disease  has  become  arrested  in  the  centre  of  a 
nodule,  with  the  appearance  of  caseation,  its  growth  in  a  peripheral 
direction  pursues  the  same  relentless  course.  The  bacilli  multiply  in 
recent  tubercular  tissues,  and  are  carried  beyond  tlie  peripheral  zone 
into  the  surrounding  tissues,  where  new,  independent  foci  of  infection 
are  thus  established,  which,  in  the  course  of  time,  pass  through  the  same 
series  of  pathological  changes  as  the  primary  nodules.  It  is  a  well- 
known  clinical  fact  that  acute  miliary  tuberculosis  is  not  a  primar}-  affec- 
tion, as  in  all  such  cases  a  careful  post-mortem  examination  will  reveal 
the  presence  of  a  cheesy  focus  in  a  lymphatic  gland,  the  lungs,  testicles, 
a  joint,  or  bone,  or  some  other  organ,  from  which  the  infection  occurred. 
Weber  found  chees}'^  foci  in  16  cases  of  tuberculosis  of  serous  mem- 
branes. The  cheesy  mass  may  lie  latent  so  long  as  it  is  solid,  but  as 
soon  as  it  liquefies  the  spores  which  it  contains  can  be  taken  up  by  the 
blood-vessels  and  prove  a  cause  of  general  infection. 


446  PRINCIPLES   OF    SURGERY. 

CALCIFICATION. 

One  of  nature's  meiiiis  in  i)rc'venting  the  local  extension  of  tubercle 
and  in  guarding  against  regional  and  general  infection  is  calcification  of 
the  tubercular  product.  This  can  only  occur  as  a  secondary  condition 
in  tubercles  that  liave  undergone  caseation.  Calcification  implies  the 
removal  of  the  cheesy  material  and  the  substitution  for  it  of  inorganic, 
calcareous  material.  It  is  a  process  which  greatly  resembles  petrifaction. 
Arrest  of  the  tubercular  process  by  caseation  and  calcification  frequently 
takes  place  in  the  lungs,  and,  occasionally,  in  the  lymphatic  glands. 


CHAPTER  XVITI. 

Clinical  Forms  of  Surgical  Tuberculosis. 

It  is  but  a  few  years  since  it  was  thought  impossible  that  any  other 
organ  than  the  lungs  should  be  the  seat  of  tuberculosis.  The  different 
forms  of  surgical  tuberculosis  that  will  be  described  below  were  not  cor- 
rectly understood  until  quite  recently,  and  consequently  a  rational  sur- 
gical treatment  was  out  of  question.  Most  all  of  the  localized  tubercular 
processes  were  included  under  the  general  term  scrofula,  and  were 
regarded  as  local  manifestations  of  a  general  dyscrasia,  and  treated  in 
accordance  with  this  view  of  their  patholog3^  The  discovery  of  the 
bacillus  of  tuberculosis  has  rendered  the  word  scrofula  obsolete,  and  has 
assigned  to  the  tubercular  processes  in  the  various  organs  and  tissues  of 
the  body  their  correct  etiological  and  pathological  significance,  and 
paved  the  way  for  their  successful  surgical  treatment.  There  is  hardly 
a  tissue  in  the  body  which  ma}'  not  become  the  primar}'  seat  of  tuber- 
cular infection,  or  which  escapes  when  diffuse  dissemination  occurs 
through  the  medium  of  the  general  circulation.  The  frequency  of 
tubercular  affections  is  something  appalling.  At  least  1  person  out  of 
every  7  dies  of  some  form  of  tuberculosis.  Most  of  the  large  hospitals 
contain  from  25  to  50  per  cent,  of  patients  afflicted  with  this  disease. 
The  ravages  of  the  disease  are  to  be  seen  everywhere,  in  the  shape  of 
disfiguring  scars  of  the  neck,  deformed  limbs,  and  bent  spines.  Health 
resorts,  frequented  for  years  by  tubercular  patients,  have  become  infected 
to  such  an  extent  that  there  is  great  danger  of  the  whole  population 
becoming  exterminated  by  this  disease.  The  sources  of  infection  in  such 
places  have  become  so  numerous  that  it  is  unsafe  to  breathe  the  air,  to 
drink  the  water,  or  to  eat  the  food  prepared  in  houses  which  for  3'ears 
have  been  hot-beds  for  the  bacillus  of  tuberculosis,  and  by  persons  car- 
rying the  microbe  upon  ever}-  square  inch  of  their  surface.  That  whole 
communities  and  nations,  where  this  disease  has  been  prevalent  for  cen- 
turies, have  not  been  completely  depopulated  long  ago  is  owing  to  the 
fact  that  many  persons  possess,  from  the  time  of  their  birth,  a  degree 
of  resistance  to  infection  that  even  direct  infection  b}'  inoculation 
would  prove  harmless.  The  bacillus  is  not  the  sole,  but  the  essential, 
cause  of  tuberculosis. 

(447) 


448  PRINCIPLES    OF    SURGERY. 

HEREDITARY    AND    ACQUIRED    PREDISPOSITION. 

Almost  every  uuthor  recognizes,  as  an  iniportiint  element  in  the 
etiology  of  tuberculosis,  the  existence  of  a  hereditary  or  acquired  pre- 
disposition. Little  is  known  in  reference  to  the  real  nature  of  such  a 
predisposition.  A  weakness  of  the  lymphatic  vessels  in  scrofulosis  was 
recognized  b>'  Sylvius  as  early  as  1695,  by  Portal  in  1690,  and  still  later 
by  Bell,  Percival  Pott,  Hufeland,and  Broussais.  Fox  is  of  the  opinion 
that  a  disposition  to  tuberculosis  is  created  by  certain  anatomical  or 
physiological  defects  in  the  Ijniphatic  system.  The  cause  of  scrofula 
was  ascribed  by  Virchow  to  a  weakness  or  imperfection  in  the  arrange- 
ment of  the  lymphatic  system  ;  by  Hueter  to  a  dilatation  of  lymph- 
spaces  ;  and  by  Billroth  to  a  constitutional  anomal}'.  Mordhorst  regards 
a  slugiiish  circulation,  the  consequence  of  superficial,  imperfect  respira- 
tion, by  causing  ca[)ilhiry  stasis  and  favoring  inflammatorj^  exudation,  a 
potent  factor  in  producing  that  peculiar  vulnerability  of  the  tissues  in 
scrofulous  subjects.  Rokitansky  placed  great  stress  on  the  importance 
of  an  imperfect  circulatory  and  respirator}'  apparatus  as  a  predisposing 
cause  of  tuberculosis.  In  1871  Friedlixnder  suggested  that  in  cases  of 
tuberculosis  there  might  be  present,  and  active,  a  fusion  of  the  scrofu- 
lous and  tubercular  diathesis, — a  view  which  was  indorsed  b}^  Charcot  in 
1877.  Aufrecht  claims  that  the  disposition  to  the  origin  of  tubercle 
may  be  found  in  the  lymphatic  vessels.  Riedel  defines  the  hereditary 
predisposition  to  tuberculosis  as  consisting  in  a  [)eculiar  defect  in  the 
anatomical  arrangement  of  the  tissues,  especially'  of  the  Ij'mphatic 
glands,  which  furnish  a  favorable  soil  for  infection.  Schiiller  believes 
that  the  noxae  of  tuberculosis  excite  a  slow  form  of  inflammation,  with 
a  tendenc}^  to  speedy  retrograde  metamorphosis  of  the  new  material. 
Quincke  recognized  a  close  relationship  between  scrofula  and  tubercu- 
losis, when  he  says  :  "  Scrofulous  persons  are  especially  predisposed  to  tu- 
berculosis; tuberculosis  hardly  ever  occurs  except  in  scrofulous  persons." 
Ziegler  w^as  aware  that  pulmonary  phthisis  is  the  most  frequent  cause  of 
death  in  scrofulous  patients.  Whittier,  in  comparing  the  etiology  of 
tuberculosis  with  sypliilis,  makes  use  of  the  following  very  positive 
language  : — 

"  There  is  no  such  a  thing  as  a  predisposition  to  either  disease. 
Eitlier  a  man  has  syi)liilis,  or  he  has  it  not.  One  m.in  is  not  more  pre- 
disposed to  either  disease  than  another.  Syphilis  affects  one  individual 
more  than  another  because  it^  virus  finds  a  better  lodgment  upon 
mucous  membrane.  Tuberculosis  finds,  also,  fortuitously,  a  better  nidus 
in  one  case  than  another.  The  virus  of  tuberculosis  is  lodged,  in  one 
case,  and  not  coughed  up,  just  as  in  syphilis  the  virus  is  secreted  and 
not  washed  off."      And   again:  "From  an}' chancre,  plaque,  gumma,  or 


HEREDITARY    AND    ACQUIRED    PREDISPOSITION.  449 

other  deposit  of  syphilis,  re-absorption  ma}'  take  place  at  any  time,  and 
re-infection  with  syphilis ;  or,  hetter,  re-appearance  of  external  signs. 
So  from  an}-  caseous  nodule,  wherein  the  tuberculous  virus  is  locked  up 
in  temporary  innocence,  absorption  may  take  place  under  favoring  cir- 
cumstances, and  a  new  outbreak  of  tuberculous  symptoms  appear,  the 
quantity  of  virus  thus  set  free  determining,  to  a  great  extent,  perhnps, 
the  virulence  of  the  symptoms.  While  the  virus  is  thus  locked  up,  the 
disease  is  latent ;  when  set  free,  it  is  manifest."  W3'nne  Foot  say-s  : 
"  Tubercles  are  small-celled  overgrowths  of  lymphatic  tissue  that  have 
preserved  such  uniformity  of  size,  color,  and  shape  as  to  have  long- 
suggested  the  probabilit}'  of  their  lymphatic  origin,"  Wilson  Fox 
regarded  tubercle  as  an  overgrowth  or  hyperplasia  of  lymphatic  tissue 
resulting  from  irritation  of  the  lymphatic  elements. 

Savor}',  in  speaking  of  the  relation  of  scrofula  to  tubercle,  remarks  : 
"  It  appears  to  me  that  there  is  nothing  sufficient  to  warrant  the  patho- 
logical distinction  which  it  is  now  the  fashion  to  make  between  scrofula 
and  tul)ercle."  And  further  :  "  Tubercle  may  be  said  to  be  the  essential 
element  of  scrofula."  According  to  Rokitansk}-,  the  most  frequent  seat 
of  tubercle  in  children  is  in  the  lymphatic  glands,  Virchow  maintained 
that  scrofula  constitutes  the  basis  of  tubercle,  and  that  in  man  tubercu- 
losis depends  in  general  on  scrofula.  He  asserts,  further:  "  On  account 
of  the  histological  identit}'  of  the  scrofulous  and  tubercular  new  growths, 
it  is  often  impossible,  in  a  given  tubercular  lesion,  to  determine  how 
much  is  inflamniator}^  and  how  much  is  tubercular."  From  the  above 
quotations  it  becomes  apparent  that  nearh'  all  of  the  older  authors 
recognized,  if  not  the  identit}',  at  least  a  close  relationship  between 
scrofula  and  tuberculosis.  The  identity  of  scrofula  and  tuberculosis  was 
established  not  upon  anatomical  or  pathological  rt'searchos,  but  was 
deflnitel)'  settled  by  the  discovery  of  the  same  cause  in  the  local  lesions 
of  both.  The  demonstration  of  any  definite  anatomical  defect,  heredi- 
tary or  acquired,  which  acts  as  a  predisposing  cause  to  tubercular  infec- 
tion, has  so  far  not  succeeded.  Only  a  few  years  ago  Formad  made 
some  interesting  studies  concerning  the  histological  structures  of  tissues 
that  are  known  to  be  prone  to  tubercular  infection,  and  he  believed  that 
the  changes  constantly  found  were  such  that  favored  the  arrest  of 
migrating  cells.  It  is  more  probable  that  the  hereditar}^  or  acquired 
predisposition  to  tuberculosis,  which  must  now  be  recognized  as  nn 
important  element  in  the  causation  of  the  disease,  must  be  regarded  rather 
as  a  diminution  of  the  power  of  resistance  inherent  in  the  tissues  to  the 
action  of  the  specific  microbic  cause  than  any  characteristic  anatomical 
cell  defects.  From  a  clinical  stand-point,  it  is  important  to  remember 
that  in  the  causation  of  tuberculosis  we  must  recognize  a  combination 

29 


450  PRINCIPLES   OF   SURGERY. 

of  etiological  factors,  viz.:  (1)  local  or  general  conditions,  resulting 
fi'om  hereditary  or  acquired  causes,  wiiich  diniinisli  tlie  resisting  capacity' 
of  tlie  tissues  to  the  action  of  the  bacillus  of  tuberculosis,  which  must 
be  regarded  as  the  predisposing  cause;  and  (2)  the  presence  in  the 
tissues  of  the  essential  cause  of  the  disease — the  bacillus  of  tuberculosis. 
The  predisposing  cause  can  under  no  circumstances  result  in  tuber- 
culosis without  action  of  the  essential  cause,  and  the  bacillus  of  tubercu- 
losis is  most  certain  to  produce  its  specific  pathogenic  effect  in  tissues 
debilitated  by  hereditary  or  acquired  causes.  The  different  avenues 
through  which  infection  takes  place  will  be  referred  to  in  the  further 
discussion  of  the  subject  which  heads  this  chapter. 

TUBERCULAR    ABSCESS. 

Pathological  Anatomy. — The  effect  of  the  bacillus  of  tuberculosis  on 
the  tissue  is  to  produce  a  chronic  inflammation,  which  invariabl}^  results 
in  the  production  of  granulation  tissue.  The  embr3'oual  cells  furnish,  as 
it  were,  a  wall  of  protection  for  the  surrounding  healthy  tissue.  The 
characteristic  pathological  feature  of  ever}'  tubercular  product  consists 
in  the  tendency  of  the  cells  of  which  it  is  composed  to  undergo  early 
degenerative  changes,  which  are  caused  by  local  ana?mia  and  the  specific 
chemical  action  of  the  ptomaines  of  the  tubercle  bacilli,  and  consist  in 
coaguhition  necrosis,  caseation,  and  liquefaction  of  the  cheesy  material 
into  an  emulsion,  which  has  always  been  regarded  as  pus,  until  recent 
investigations  have  sliown  tliat  it  is  simpl}'  the  product  of  retrograde 
tissue  metamorphosis,  and  not  true  pus.  I  believe  that  it  can  now  be 
considered  as  a  settled  fact  that  the  bacillus  of  tuberculosis  is  not  a  pyo- 
genic microbe,  and  that  in  the  absence  of  other  microbes  it  produces  a 
specific  form  of  chronic  inflammation,  which  invariably  terminates  in  the 
formation  of  granulation  tissue;  and  that  when  true  suppuration  takes 
place  in  the  tubercular  product  it  occurs  in  consequence  of  secondary 
infection  with  pus-microbes.  The  so-called  tubercular,  or  cold,  abscess 
contains  a  fluid  which  macroscopically  resembles  pus,  but  which,  when 
examined  under  the  microscope,  shows  none  of  its  histological  elements. 
If  the  ])acillus  of  tuberculosis  meets  with  sufficient  resistance  on  the 
i:)art  of  the  surrounding  tissues,  it  finally  exiiausts  the  nutrient  material 
in  the  granulations  and  dies,  or  remains  in  a  latent  condition  ;  the  granu- 
lation material  is  converted  into  cicatricial  tissue  and  the  local  lesion  is 
cured.  The  cases  in  which  the  tubercular  product  is  removed  by  cica- 
trization terminnte  most  frequently  in  spontaneous  cure.  If,  on  the 
other  hand,  bacilli  in  sufficient  number  are  present  to  destroy  the  granu- 
lation cells,  congulation  necrosis,  caseation,  nnd  liquefaction  of  the  in- 
fected tissue  take  place;  a  spontaneous  cure  is  still  possible  if  a  part 


TUBERCULAR    ABSCESS.  451 

of  the  fluid  portion  is  absorbed  and  the  solid  debris  becomes  encapsu- 
lated. The  same  favorable  termination  is  expedited  under  similar  cir- 
cumstances if  the  primary  lesion  has  healed,  and  the  iiillammatory 
l^roduct  is  removed  b}'  operative  interference  under  the  strictest  anti- 
septic precautions,  or  if,  at  the  same  time,  the  primary  focus  can  be 
completely  removed  bj'  extending  the  operation  to  the  i)rimary  lesion. 
Secondary  infection  of  a  tubercular  product  with  pus-microbes  without 
a  direct  infection-atrium  is  possible,  and  if  the  primary-  lesion  is  located 
in  an  unimportant  organ,  and  in  such  a  place  where  the  inflammator}^ 
product  can  be  earlj-  reached  or  can  be  disehnrged  spontaneous^^,  a  cure 
is  often  effected,  as  the  suppurative  inflammation  may  destro}-  all  of  the 
tissues  inhabited  b}-  the  bacillus,  and  the  whole  nidus,  with  the  microbes 
it  contains,  is  eliminated  permanently  from  the  bod}'.  Such  a  course  is 
not  infrequently  observed  in  cases  of  tuberculosis  of  the  lymphatic 
glands  of  the  neck.  If,  however,  the  tuberculnr  process  affects  important 
organs  or  ports  deeply  located  with  extensive  infection  of  tissue,  and 
secondary  infection  with  pus-microbes  takes  place,  then  the  patient 
incurs  the  danger  of  septic  infection  and  local  and  general  dissemina- 
tion of  the  tubercular  process  from  the  breaking  down  of  the  protective 
wall  of  granulation  tissue.  That  the  bacilli  do  not  grow  in  a  tubercular 
abscess  has  been  definitely  settled  by  Schlegtendal.  He  examined  520 
specimens  of  fluid  from  tubercular  abscesses,  and  found  bacilli  present 
in  only  75  per  cent.  Garre  has  also  made  an  extended  series  of  observa- 
tions to  ascertain  the  presence  of  the  bacillus  in  cold  abscesses.  Accord- 
ing to  this  author,  many  tubercular  ulcerations  and  abscesses  are  the 
result  of  a  mixed  infection,  as  has  been  claimed  by  Hoffa  for  some  cases 
of  empj-ema  complicating  pulmonary  or  pleural  tuberculosis.  In  cold 
abscesses,  and  in  the  liquefied  cheesy  material  of  tubercular  cavities  in 
bone,  no  pus-microbes  could  be  fovmd ;  not  even  in  cases  that  pursued  a 
rapid  course.  Cultivations  of  such  material  remained  sterile,  while 
inoculations  produced  tvpical  tuberculosis.  Such  specimens,  examined 
iinder  the  microscope,  showed  none  of  the  morphological  elements  of  pus, 
Init  were  seen  to  consist  of  an  emulsion  composed  of  fat-globules  and 
detritus  of  broken-down  tissue  suspended  in  serum. 

Garr^  believes  it  is  possible  that,  in  many  cases  of  suppuration  fol- 
lowing in  the  course  of  a  tubercular  process,  pus  is  the  result  of  a  mixed 
infection,  and  that  the  pus-microbes  disappear  before  the  examination  is 
made.  The  walls  of  the  tubercular  cavit^^  contain  the  typical  structure 
of  the  tubercular  lesion  and  the  primary  and  essential  cause  of  the  in- 
flammation, the  bacillus  tuberculosis.  The  infection  follows  the  migra- 
tion of  the  abscess  in  whatever  direction  that  may  take  place.  If  an 
additional  infection  from  without  take  place,  following  either  a  spon- 


452  PRINCIPLES   OF    SURGERY. 

tiineoiis  discharge  or  after  incision,  the  superficial  granuhitions 'are 
destro^'ed  by  the  suppurative  process  which  is  initiated,  exposing  the 
patient  to  the  additional  risks  of  septic  infection  and  a  more  rapid  local 
and  general  dissemination  of  the  tubercular  process. 

Symptoms  and  Diagnosis.— The  tubercular  abscess  is  called  a  cold 
abscess  because  it  lacks  the  characteristic  clinical  phenomena  which 
attend  the  development  of  an  acute  or  hot  abscess.  There  is  but  little, 
if  an}',  rise  of  the  local  temperature,  and,  unless  the  abscess  has  reached 
the  skin,  looks  rather  preternaturall_y  pale  than  red,  and  the  abscess 
itself  is  always  painless  and  not  tender  on  pressure.  The  pain,  if 
l)resent,  is  referred  to  the  priniar^^  seat  of  the  tiibercular  inflammation. 
Fluctuation  is  usually  well  mnrked,as  the  tissues  around  the  abscess  are 
not  much  infiltrated.  The  most  important  clinical  feature  of  a  cold 
abscess  is  its  tendency  to  wander  from  the  place  where  it  originated  to 
distant  localities  by  gravitation  ;  hence  the  name  given  to  it  by  German 
writers,  senkxmgs  absce.'tii.  Thus,  in  tubercular  spondylitis,  the  abscess 
raa}^  appear  in  the  lumbar  region,  and  is  then  called  lumbar-  abscess;  it 
may  follow  the  iliac  muscle  and  appear  in  one  of  the  iliac  regions,  and  is 
then  called  iliac  abscess ;  or,  finally,  it  ma}^  follow  the  psoas  muscle  and 
appear  above  or  below  Pou part's  ligament,  when  it  constitutes  a  psoas 
abscess. 

In  tuberculosis  of  the  hip-joint  the  abscess  appears  posteriorly 
underneath  the  gluteal  muscles,  if  perforation  of  the  capsule  in  this 
direction  take  place  ;  or  it  appears  anteriorlj'  a  considerable  distance 
below  the  hip-joint,  if  perforation  of  the  capsule  take  place  in  an  oppo- 
site direction.  As  the  contents  of  the  abscess  carry  the  original  cause 
of  the  disease,  infection  of  the  tissues  takes  place  along  the  whole  course 
of  the  abscess,  which  is  alwaj^s  lined  with  infected  granulation  tissue. 
Although  the  primary  cause  of  a  tubercular  abscess  is  most  frequently  a 
tuberculosis  of  a  joint  or  bone,  it  can  also  develop  in  the  course  of  any 
localized  form  of  tuberculosis,  and  it  is  quite  frequently  met  in  the  course 
of  tuberculosis  of  the  lymphatic  glands.  The  diagnosis  must  be  made 
with  special  reference  to  the  nature  and  location  of  the  primar}^  lesion. 
In  tuberculosis  of  the  spine  the  fixed  pain  in  the  region  of  the  affected 
vertebrae,  radiating  from  here  in  the  direction  of  the  nerves  on  each  side, 
is  an  important  S3mptom,  and  this  symptom  is  always  aggraA'ated  by 
flexion  and  ameliorated  by  extension  of  the  spine.  In  coxitis  the  pain 
in  the  beginning  of  the  disease  is  usually  referred  to  the  inner  aspect  of 
the  knee-joint,  but  is  always  increased  b}^  motion  in  the  hip-joint.  In 
cold  abscess,  caused  by  glandular  tuberculosis,  the  clinical  history  will 
point  to  a  chronic  inflammation  of  the  glands  which  preceded  the  forma- 
tion of  the  abscess.     As  soon  as  the  abscess  reaches  the  skin  that   struc- 


TUBERCULAR    ABSCESS.  4.53 

ture  becomes  inflamed,  red,  and  more  and  more  attenuated  b^'  pressure 
and  inflammation,  until  spontaneous  perforation  takes  place  at  a  point 
subjected  to  greatest  pressure.  If  a  tubercular  product  become  the 
seat  of  a  secondary  infection  with  pus-microbes,  the  subsequent  symp- 
toms, local  and  general,  are  those  of  suppurative  inflammation.  The 
temperature,  which  was  normal,  or  nearl}-  so,  increases  and  presents  the 
daily  curves  indicative  of  suppuration,  while  the  abscess,  which  has  been 
painless  heretofore,  becomes  painful  and  tender  on  pressure  ;  in  fact,  a 
chronic  inflammation  has  been  supplanted  by  an  acute  one,  with  a  cor- 
responding change  of  the  clinical  picture.  If  any  doubt  remain  as  to 
the  character  of  the  swelling  and  the  nature  of  its  contents,  this  can  be 
dispelled  at  once  b}'  resorting  to  an  exploratory  puncture.  In  cold 
abscess  the  fluid  removed  presents  the  appearance  of  serum  in  which 
minute  particles  of  broken-down  tissues  are  suspended,  while  in  an 
abscess  caused  b^^  a  mixed  infection  it  presents  the  macroscopical  and 
microscopical  appearances  of  pus. 

Prognosis. — The  danger  attending  tubercular  abscess  must  be  esti- 
mated exclusively  b}-  the  extent  and  location  of  the  primary  disease  and 
the  presence  or  absence  of  tuberculosis  in  other  organs.  If  the  general 
health  remain  unimpaired,  even  an  extensive  local  tubercular  disease 
may  be  amenable  to  a  spontaneous  cure  or  successful  surgical  treatment. 
On  the  other  hand,  a  tubercular  abscess  developing  in  the  course  of  an 
insignificant  and  unimportant  local  lesion  occurring  in  an  anaemic  person, 
the  subject  of  incipient  multiple  foci  in  difl^erent  organs,  must  be  regarded 
as  a  formidable  condition,  with  little  or  no  prospects  of  a  favorable  ter- 
mination. I  have  learned  to  regard  pronounced  anaemia  as  an  unfavor- 
able symptom  in  the  different  forms  of  surgical  tuberculosis,  as  it  is  often 
an  exp)ression  that  general  infection  has  occurred.  Another  important 
matter  to  be  taken  into  consideration,  in  making  a  prognosis  in  cases 
where  general  infection  can  be  excluded,  is  the  possibility  of  eradicating 
the  primary  lesion  b^^  operative  interference.  Where  this  can  be  done, 
the  chances  of  successful  treatment  of  the  local  disease  are  much  better; 
at  the  same  time,  the  removal  of  all  the  infected  tissues  is  the  best 
guarantee  against  general  infection.  Other  things  being  equal,  the 
prognosis  is  lietter  in  patients  without  a  hereditary  history-  of  tuber- 
culosis, and  in  young  persons  tiian  those  advanced  in  years. 

Treatment. — The  surgical  treatment  of  large  tubercular  abscesses  is 
always  fraught  with  danger  from  the  fact  that,  even  if  conducted  under 
strict  antiseptic  precautions,  it  is  not  alwaj's  possible  to  prevent  infec- 
tion Avith  pus-microbes.  Large  tubercular  abscesses  were  a  "  nole  me 
tangere^^  to  the  older  surgeons,  as  it  was  well  known  evacuation  by 
incision   would  be  followed  within  a  few  days  bj-  hectic  fever,  profuse 


45 i  PRINCIPLES   OF    SURGERY. 

sweating,  diarrhoea,  and  other  symptoms  of  septic  infection.  The  early 
advocates  of  tlie  antiseptic  treatment  hoped  that  the  time  had  come 
when  the  surgeon  had  it  in  his  power  to  prevent  septic  infection  during 
the  operation  by  resorting  to  the  necessary  antiseptic  precautions,  and 
to  maintain  an  aseptic  condition  tlirougliout  the  after-treatment  under 
an  ellicient  antiseptic  hygroscopic  occlusive  dressing.  If  we  remember 
that  in  cases  wiiere  the  abscess  originated  from  a  primary  lesion  inac- 
cessible to  direct  treatment  it  may  require  months  for  the  healing 
process  to  be  completed,  it  is  not  surprising  that  even  the  strictest 
antiseptic  precautions  in  the  hands  of  the  ablest  surgeons  have  failed 
in  protecting  the  abscess-cavity  against  septic  infection  for  such  a  long 
time. 

In  a  number  of  tubercular  abscesses  originating  from  a  tubercular 
focus  in  the  vertebra,  in  the  hip-  and  knee-joints,  I  have  succeeded  in 
preventing  infection,  and  the  patients  were  cured  after  several  months 
of  the  most  careful  and  watchful  treatment;  but  in  a  greater  number  of 
eases  infection  occurred  at  the  time  of  operation,  or  weeks  or  months 
later  during  change  of  the  dressing,  or  in  consequence  of  a  slipping  of 
the  dressing.  In  abscesses  in  the  gluteal  or  inguinal  regions,  especially 
in  children  treated  by  incision  and  drainage,  it  is  almost  next  to  im- 
possible to  maintain  an  aseptic  condition  for  weeks  and  months,  and  the 
most  careful  and  laborious  efforts  in  this  direction  will  often  result  in 
failure. 

(a)  Evacuation  by  Aspiration  followed  by  Antiseptic  irrigation  and 
Subcutaneous  lodoformization. — The  frequency  with  which  failures  have 
occurred  after  incision  and  drainage,  in  the  hands  of  the  most  enthu- 
siastic followers  of  the  antiseptic  treatment,  has  again  aroused  the  fear 
of  surgeons  in  attacking  large  tubercular  abscesses  by  incision  and 
drainage,  and  the  subcutaneous  evacuation  with  subsequent  disinfection 
of  the  abscess-cavit^'  has  again  come  into  favor.  That  iodoform  exerts 
an  inhibitory  effect  on  the  groMth  of  the  bacillus  of  tuberculosis  is  now 
generally  accepted.  Its  use  in  the  treatment  of  tubercular  affections  is 
almost  universal.  It  has  been  extensively^  used  for  injection  into  tuber- 
cular abscess,  after  evacuation  b}^  aspiration,  since  Bruns  advocated  this 
treatment,  in  1887.  It  was  first  used  dissolved  in  ether  in  the  proportion 
of  1  part  to  20.  The  ethereal  solution  has  the  advantage  of  bringing 
the  drug  in  contact  with  everj^  part  of  the  interior  of  the  cavity  by  the 
distention  which  takes  place  from  the  expansion  of  the  ether  when 
exposed  to  the  bod}- -temperature,  but  the  injection  is  usually  followed 
by  considerable  pain.  Bruns  used  a  suspension  of  iodoform  in  glycerin 
and  alcohol.  Recently  the  following  formula  was  suggested  by 
Krause : — 


TUBERCULAR    ABSCESS.  4:55 

lodoformi  subt.  pulveris, 60.0 

Mucil.  gummi  arab., 23.0 

Glycerini, 83.0 

Aquae  destillatae, q.  s.  ad  500.0 

(Ten-per-cent.  iodoform  mixture.) 

The  evacuation  of  the  abscess  is  to  be  done  with  an  ordinary  trocar 
under  strict  antiseptic  precautions.  Tiie  surface  of  the  abscess  is  thor- 
oughly disinfected  in  the  usual  manner,  and  the  instruments  rendered 
aseptic  by  boiling.  The  trocar  is  inserted  in  such  a  manner  that  a  track, 
at  least  an  inch  in  length,  is  made  underneath  the  skin  before  the  instru- 
ment is  plunged  into  the  abscess-cavity,  in  order  to  make  the  wound, 
after  the  removal  of  the  instrument,  as  nearly  as  possible  subcutaneous. 
As  tubercular  abscesses  usually  contain  shreds  of  dead  connective  tissue 
and  masses  of  broken-down  granulation  tissue,  the  evacuation  is  often 
attended  by  a  considerable  difficulty,  as  these  substances  block  the  open- 
ing of  the  instrument  and  thus  prevent  evacuation.  The  simplest  pro- 
cedure to  overcome  these  difficulties  is  to  introduce  through  the  canulaa 
small  hook  made  b}'  bending  an  aseptic  wire,  and  to  extract  with  it  any 
substance  which  interferes  with  the  escape  of  the  fluid  contents.  Gentle, 
uniform  pressure  is  of  great  value  in  expediting  the  escnpe  of  the  con- 
tents and  in  preventing  the  entrance  of  air.  lodoformization  of  the 
abscess-cavity  is  not  to  be  done  until  complete  evacuation  of  solid  de- 
tached particles  has  been  effected  by  means  of  irrigation  with  a  3-per- 
cent, solution  of  boracic  acid.  This  can  be  readily  done  by  inserting  the 
glass  tip  of  an  irrigator  which  holds  the  solution  into  the  canula.  A 
sufficient  quantity  of  fluid  is  allovved  to  flow  into  the  cavity  until  this  is 
distended  as  much  as  before  the  evacuation  of  the  fluid,  when,  by  gentle 
pressure,  it  is  forced  out  thi'ough  the  canula.  By  filling  and  emptying 
the  cavity  alternately  in  this  manner  a  requisite  number  of  times,  com- 
plete evacuation  of  the  fluid  and  loose  solid  contents  is  ett'ected,  and  the 
cavity  is  now  ready  for  lodoformization.  Whatever  formula  for  the 
solution  is  selected,  not  more  than  half  a  drachm  of  the  iodoform  should 
be  injected  at  the  first  time,  and  in  children  even  less.  If  this  dose  does 
not  produce  any  unpleasant  symptoms,  it  may  be  increased  the  next 
time  the  operation  is  repeated.  There  seems  to  be  very  slight  danger  of 
iodoform  intoxication,  not  even  a  symptom  of  tliis  being  observed  in 
109  cases  thus  treated  by  Bruns,  of  TUbingen.  The  injection  is  made 
with  an  ordinary  but  perfectly  aseptic  syringe,  the  nozzle  of  which  must 
fit  accurately  into  the  outer  end  of  the  canula.  If  the  ethereal  solution 
is  used,  the  iodoform  will  become  diffused  over  the  entire  inner  surface 
of  the  abscess-cavitN'  ;  but  if  a  non-evaporating  medium  for  the  mixture 
is  used,  this  must  be  done  bj-  gently  kneading  and  rubbing  the  parts 


456  pRiNCiPL?:s  OF  surgery. 

over  the  abscess  after  the  camihi  is  witlulrawn.  Tlie  injection  containing 
the  iodoform  is,  of  course,  intended  to  remain  in  the  cavity.  The  punc- 
ture in  the  slcin  is  closed  with  collodium,  and  the  walls  of  the  abscess  are 
kept  in  contact  b}'  compress  and  bandage.  Absolute  rest  is  to  be  en- 
forced for  some  time  b^-  splints  or  confinement  in  bed,  according  to  the 
location  of  the  abscess.  The  operation  is  to  be  repeated  in  the  course 
of  a  week,  or  as  soon  as  the  abscess-cavity  has  partially  refilled.  The 
treatment  of  tubercular  abscesses  by  subcutaneous  evacuation,  with  sub- 
sequent iodoformization,  should  be  adopted  and  repeated,  from  time  to 
time,  in  all  cases  where  the  primary  lesion  is  inaccessible  to  radical 
surgical  treatment,  and  ma}'  yield  good  results  in  cases  which  heretofore 
had  been  subjected  to  heroic  surgical  treatment  from  the  beginning.  It 
ma}'  also  prove  useful  as  a  preparatory  treatment  in  cases  which  subse- 
quently require  operative  treatment. 

(b)  Incision  and  Removal  of  Primary  Focus. — In  all  cases  where, 
from  the  anatomical  location  of  the  [trimary  lesion,  it  is  possible  to 
remove  the  tubercular  product  b}'  operative  interference,  and  the  patient 
is  free  from  other  tubercular  affections,  a  radical  operation  is  absolutely 
indicated.  In  such  cases  the  abscess-cavity  is  laid  freely  open  in  a 
direction  wliich  will  secure  most  ready  access  to  its  interior  with  least 
injur}'  to  surrounding  parts.  After  the  abscess  has  been  opened,  its  con- 
tents are  waslied  away  by  irrigating  with  an  aqueous  solution  of  iodine, 
after  which  the  granulations  lining  the  cavity  are  scraped  out  with  a 
sharp  spoon,  and  the  primary  lesion  is  removed  in  a  similar  manner.  In 
dealing  with  such  cavities  it  is  important  not  to  forget  that  the  granula- 
tions contain  tubercle  bacilli,  and,  if  they  are  not  thoroughly  removed,  the 
principal  object  of  the  operation — removnl  of  the  primary  cause — has  not 
been  accomplished,  and  a  return  of  the  disease  is  to  be  expected.  If  the 
abscess  communicates  with  a  primary  focus  in  the  bone,  it  is  advisable 
to  resort  to  ignipuncture  of  the  bone  after  the  cavity  has  been  cleared 
of  the  granulations  with  the  sharp  spoon.  The  wound  is  to  be  closed  in 
the  usual  manner,  leaving  only  a  small  opening  at  the  most  dependent 
point  for  drainage.  The  scraped  surfaces  are  now  in  the  same  conditions 
for  primary  union  as  a  recent  aseptic  wound,  and,  if  kept  in  accurate 
apposition  by  the  antiseptic  dressing,  which  answers  at  the  same  time 
the  purpose  of  a  compress,  primary  union  throughout  is  frequently  ob- 
tained. Abscesses  which  have  opened  spontaneously,  or  during  the 
treatment  of  which  infection  has  occurred,  must  be  treated  on  the  same 
principles  as  acute  abscesses.  As  far  as  can  be  done,  the  suppurating 
granulations  should  be  removed  with  the  sharj)  spoon  and  efficient 
tubular  drainage  established,  and  by  frequent  antiseptic  irrigations  an 
attempt  is  made  to  prevent  septic  infection.    Landerer  has  recently  called 


TUBERCULOSIS    OF    THE    INTERNAL    EAR.  -457 

attention  to  the  value  of  balsam  of  Peru  in  the  treatment  of  tubercular 
affections.  He  claims  that  this  drug  acts  beneficiall}'  by  stimulating  the 
tissues  to  renewed  activit}',  thus  neutralizing,  at  least  to  a  certain  degree, 
the  pathogenic  effect  of  the  bacilli.  Sayre,  of  New  York,  has  used  this 
remed}'  for  more  than  thirty  j-ears  in  the  treatment  of  tubercular  joints, 
and  his  results  have  certainl}-  been  extrerael}-  satisfactor}-.  In  the  treat- 
ment of  open,  suppurating,  tubercular  cavities,  the  balsam  of  Peru  should 
be  tried  as  a  local  ai^plication.  As  a  fluid  for  irrigation  under  the  same 
circumstances,  nothing  can  surpass  the  efficac}'  of  a  strong  aqueous  solu- 
tion of  tincture  of  iodine. 

(c)  General  Treatment. — Patients  suffering  from  suppurating  tuber- 
cular cavities  require  nutritious  food,  ale,  porter,  or  some  of  the  substantial 
wines  ;  out-door  air  will  often  prove  the  best  tonic.  Change  of  residence 
to  the  sea-shore  or  some  mountain  resort  has  often  been  known  to  effect 
a  cure  when  recovery  was  despaired  of  as  long  as  the  patients  lived  in 
localities  less  favorabl}'  located.  In  the  way  of  medication  the  treatment 
must  be  purely  symptomatic.  Appetite  is  restored  b3'  the  use  of  bitter 
tonics ;  anaemia  is  treated  by  the  administration  of  some  mild  prepara- 
tion of  iron,  as  the  S3'rup  of  iodide  of  iron,  tincture  of  chloride  of  iron, 
albuminate  of  iron,  or  citrate  of  iron.  If  codliver-oil  is  given  it  should 
be  administered  pure,  and  not  in  emulsion,  and  never  upon  an  empty 
stomach.  The  pale  Norwegian  oil  is  the  best.  The  best  time  to  give 
the  oil,  without  disturbing  the  digestion,  is  an  hour  or  an  hour  and  a  half 
after  each  meal,  in  doses  of  from  a  teaspoonful  to  a  tablespoonful, 
according  to  the  condition  of  the  digestion  and  the  age  of  the  patient. 

TUBERCULOSIS    OF    THE   INTERNAL    EAR. 

That  an  ordinary  otitis  media  with  perforation  of  the  tympanum 
may  occasionally  be  transformed  into  a  tubercular  lesion  by  the  entrance 
of  tubercle  bacilli  there  can  be  no  doubt.  Habermann  has  recentl}' 
investigated  this  subject  by  examining,  post-niorteni.  18  tuberculous 
subjects,  in  whom  either  otorrha^a  or  deafness,  without  active  discharge, 
had  been  observed  during  life,  and  in  9  of  these  he  could  demonstrate  the 
presence  of  tubercular  lesions  in  the  auditor3-  canal.  In  1  case  he  found, 
in  the  left  auditory-  apparatus,  tuberculosis  of  the  entire  middle  ear  where 
the  tjnnpanum  was  intact.  In  another  tubercular  subject,  a  man  38 
3'ears  of  age.  in  whom  tuberculosis  of  the  ear  was  observed  a  year  and  a 
half  before  death,  the  post-mortem  revealed  extensive  tul)ercul()sis  of  the 
cochlea,  in  the  internal  auditor}'  canal,  and  in  the  superior  semicircular 
canal,  while  the  other  semicircular  canals  and  the  vestibule  were 
destroyed  b\'  caries.  Infection  with  the  bacillus  tuberculosis  of  granula- 
tions in  the   middle  ear  through  a  perforation  in   the  tympanum  can 


458  PRINCIPLES   OF    SURGERY. 

occur  in  persons  otherwise  in  perfect  lieiiltli.  Tlie  diagnosis  in  such 
cases  can  be  readily  made  by  removing  fragments  of  granulation  tissue 
for  microscopic  examination.  If  they  are  found  to  contain  tubercle 
bacilli  a  positive  diagnosis  has  been  made,  and  no  time  should  be  lost  in 
resorting  to  a  radical  operation.  The  removal  of  the  infected  granula- 
tions with  a  sharp  spoon,  followed  by  irrigation  with  a  warm  3-per-cent. 
solution  of  boric  acid  and  iodoformization  of  the  cavity,  are  the  measures 
to  be  emplo3-ed  in  removing  the  infected  focus  and  in  preventing  exten- 
sion of  the  disease  into  other  parts  of  the  ear,  the  mastoid  cells,  or  the 
meninges  of  the  brain. 

TUBERCULOSIS   OF    THE   IRIS. 

Inoculations  of  the  anterior  chamber  of  the  eye  with  tubercular 
material  have  shown  the  extreme  susceptibility  of  the  iris  to  tubercular 
infection.  That  this  structure  should  occasionally  become  the  seat  of 
primary  infection  is  evident  from  a  case  recently  reported  by  Griffitho 
The  patient  was  a  female  child  7  months  old.  The  eye  had  been 
affected  for  one  month  ;  there  was  an  enlarged  gland  in  the  neck  on  the 
same  side,  but  there  were  no  other  physical  signs  of  tubercle  ;  no  history 
of  heredit}'.  A  yellowish  nodule  grew  from  the  periphery  of  the  iris  of 
the  right  eye,  and  numerous  millet-seed-like  bodies  from  its  surface ;  the 
pupil  was  closed,  but  thei'e  was  no  acute  inflammation.  The  local  disease 
increased  rapidly  in  extent.  The  eye  was  enucleated  after  tliree  weeks' 
treatment.  The  disease  was  found  to  be  confined  to  the  iris  and  ciliary 
body.  Under  the  microscope  the  new  growth  showed  the  characteristic 
structure  of  tubercle.  In  32  recorded  cases,  in  which  microscopic  and 
bacteriological  tests  left  no  doubt  as  to  the  tubercular  nature  of  the 
disease,  only  1  eye  w^as  affected  in  29.  The  average  age  of  the  patients 
was  12  years;  youngest  4  months,  oldest  51  years.  In  10  cases  bacilli 
was  searched  for,  but  only  found  in  4 ;  in  1  of  the  remaining  6  cases, 
however,  the  inoculation  test  was  successful.  A  number  of  patients 
recovered  completely  and  permanently  after  enucleation. 

If  the  tubercle  is  located  on  the  anterior  surface  of  the  iris,  a  diag- 
nosis can  usuall}-  be  made  witiiout  much  difficult}'  at  an  early  stage,  as 
the  inflammatory  product  can  be  seen  and  carefully  examined  through 
tlie  transparent  cornea.  If  some  doubt  exist  at  first  as  to  the  nature 
of  the  swelling,  this  is  soon  set  aside  b^-  the  progress  of  the  disease.  The 
primar}'  nodule  soon  becomes  surrounded  and  covered  by  an  eruption 
of  miliar}^  tubercles.  The  disease  here,  as  elsewhere,  shows  its  charac- 
teristic clinical  feature, — progressive  extension,  affecting  all  the  struc- 
tures contiguous  to  or  continuous  with  the  part  primarily  affected, 
irrespective  of  their  anatomical  structure.     Glandular  infection  on  the 


TUBERCULOSIS   OF    THE    SKIN.  459 

same  side  is  an  early  and  quite  constant  occurrence.  Even  if  the  disease 
is  correctl}'  diagnosticated  at  an  early  stage,  complete  removal  by  iridec- 
tomy is  impossible,  as  parts  of  the  iris  wliicli  present  a  perfectly  normal 
appearance  may  alread}'  be  infected  and  lead  to  an  almost  certain  recur- 
rence of  the  disease.  Enucleation  of  the  affected  eye  is  onlj^  justifiable 
if  the  disease  affect  only  one  e^-e,  and  if  the  surgeon  can  satisf}'  himself 
that  the  patient  is  not  suffering  at  the  same  time  from  tuberculosis  in 
other  organs  inaccessible  to  successful  surgical  treatment. 

TUBERCULOSIS    OF    THE    SKIN. 

All  forms  of  primary-  tuberculosis  of  the  skin  are  the  result  of  direct 
inoculation  with  tubercle  bacilli.  Considering  the  frequency  with  which 
abrasions  occur  in  the  exposed  portion  of  the  skin,  and  the  innumerable 
sources  of  infection  with  the  virus  of  tuberculosis,  it  is  somewhat  strange 
that  primar}-  tubercular  lesions  of  the  skin  are  not  of  more  frequent 
occurrence.  Baumgarten  believes  that  this  is  due  to  the  slow  growth  of 
the  bacillus  and  the  dense  structure  of  the  deeper  portions  of  the  skin, — 
conditions  which  enable  the  superficial  wound  to  heal  before  the  tubercle 
bacilli  have  penetrated  the  tissues  to  a  sufficient  depth.  Considerable 
confusion  exists  at  the  present  time  in  reference  to  the  nomenclature  of 
primary  tubercular  affections  of  the  skin.  We  find  descriptions  of  what 
is  called  tuberculosis  of  the  skin,  tubei'culosis  verrucoaa  cutis,  and  lupus, 
all  of  which  affections  have  been  proved  to  be  tubercular  in  their  origin 
and  manifesting  the  same  clinical  tendencies.  It  is  time  that  these  imma- 
terial and  unimportant  distinctions  should  be  set  aside,  and  these  different 
affections  should  be  included  under  one  head,  as  ^jrimary  tuberculosis  of 
the  skii},  since  all  of  them  present  the  same  histological  structure,  and  all 
of  them  are  caused  by  direct  inoculation  with  tubercle  bacilli. 

Riehl  and  Paltauf  have  described  an  affection  of  the  skin,  under  the 
name  of  tuberculosis  verrucosa  cutis,  in  which  the  bacillus  of  tuberculosis 
is  constantly  found,  and  whicli  they  attributed  to  local  affection,  because 
all  of  the  patients  they  examined  were  persons  handling  animal  products. 
Riehl  has  also  shown  the  tubercular  nature  of  papillomatous  allections 
occurring  upon  the  hands  of  pathological  anatomists  by  finding  the 
bacillus  in  the  tissues. 

Anatomical  and  Clinical  Proofs  of  the  Tubercular  Nature  of  Lupus. 
— Lupus  vulgaris,  and  probabl}-  the  other  varieties  of  this  affection  of 
the  skin,  are  nothing  more  nor  less  than  cases  of  cutaneous  inoculation- 
tuberculosis.  It  is  well  known  that  lupus  occurs  most  frequently  in 
parts  of  the  bod}'  most  exposed  to  injury  and  infection;  that  is,  in  the 
skin  not  protected  by  the  hair  or  clothing.  Lupus  attacks  most  fre- 
quently the  nose,  face,  ej-elids,  ears,  and  hands,  localities  where  abrasions 


460  riilNCIPLES   OF    SURGERY. 

occur  most  frequently,  and  parts  upon  which  floating  microbes  are  too 
liable  to  become  deposited,  and  where  direct  inoculation  with  soiled 
hands,  handkerchiefs,  and  towels  is  most  likely  to  occur.  I  shall  quote 
from  a  number  of  reliable  authorities  at  sufficient  length  to  prove  that 
lupus  and  tuberculosis  are  identical  affections.  From  a  clinical  stand- 
point Hebra, brought  the  different  varieties  of  lupus  under  one  common 
head.  He  separated  it  entirely  from  syphilis,  but  otherwise  did  little 
to  fix  its  pathological  siguilicance.  He  adopted  the  classification  of 
Fuchs  and  the  older  French  and  English  authors,  who  taught  that  it  was 
one  of  the  manifestations  of  scrofula,  and  that  anatomicall}^  it  was 
composed  of  granulation  tissue. 

Yirchow  classified  it  with  the  granulomata,  but  denied  its  identity 
with  scrofula.  Rindfleisch  described  it  as  a  proliferation  of  epithelial 
cells, — as  a  sort  of  phthisis  cutanea.  Hueter,  who,  in  his  pathological 
views,  was  generally  far  ahead  of  his  time,  affirmed  that  it  was  a  form  of 
fungous  inflammation,  the  specilic  cause  of  which,  when  introduced  into 
the  organism,  produced  miliary  tuberculosis.  Volkmann  included  it  among 
the  affections  which  auatomicall}'  are  represented  by  granulation  tissue. 
Friedlander  Avas  the  first  to  take  a  positive  stand  in  asserting  that  lupus 
is  a  tubercular  affection  of  the  skin,  and  showed  its  histological  identity 
with  other  recognized  forms  of  local  tuberculosis.  He  demonstrated  the 
presence  of  miliary  tubercles  in  it.  The  absence  of  caseation  in  lupus, 
which  was  regarded  by  some  authors,  among  them  Baumgarten,  as  an 
evidence  of  its  nun-tubercular  character,  has  been  explained  bj^  Schiiller 
as  being  due  to  the  soil  present  in  and  around  the  nodules.  He  also 
calls  attention  to  the  fact  that  Cohnheim  and  Thoma  have  seen  caseous 
foci  in  lupus,  and  consequently  asserts  that  the  absence  of  caseation  is 
no  proof  of  the  non-tubercular  nature  of  lupus. 

Neisser  accepts  fullj'  and  pleads  strongly  in  favor  of  the  tubercular 
nature  of  lupus.  Rassdnitz  collected  209  cases  of  lupus,  and  found  that 
in  30  per  cent,  of  all  the  cases  it  was  associated  with  other  evidences 
of  tuberculosis.  He  placed,  also,  great  importance  on  the  observations 
that  lupus  is  prone  to  develop  in  the  scar  left  after  healing  of  a  localized 
tuberculosis  in  lymphatic  glands,  and  that  lupus  is  often  observed 
u[)on  t!ie  nose  or  ej'elids  in  cases  of  chronic  nasal  or  conjunctival  ca- 
tarrh. In  10  to  15  per  cent,  of  his  cases  lupus  could  be  traced  to  heredi- 
tary predisposition.  Demme  observed  miliary  tuberculosis  in  2  of  his 
cases  after  scraping  lupus.  Pontoppindau  asserted  that,  in  his  expe- 
rience, in  50  to  75  per  cent.,  patients  suffering  from  lupus  manifested  ad- 
ditional evidences  of  tuberculosis.  Quinquaud  saw  in  3  cases  of  lupus 
pulmonary  tuberculosis  appear  as  a  final  cause  of  death.  Of  38  cases 
that  came  to  the  personal  knowledge  of  Bessnier,  8  of  them  suffered 


TUBERCULOSIS   OF    THE    SKIN.  461 

from  pulmonary  phthisis.  Of  2  patients  treated  by  Aubert,  1  died  of 
acute  pulmouaiT  tuberculosis  and  the  other  of  tubercular  pleuritis  after 
scarification. 

Renoward  was  able  to  ascertain  the  existence  of  pulmonar}'  phthisis 
in  50  per  cent,  of  his  cases  of  lupus.  Block  met  with  tuberculosis  in 
other  organs,  before  or  after  the  development  of  lupus,  in  114  out  of 
144  cases.  Bender  examined  374  cases  of  lupus.  In  159  of  these  an 
accurate  history  could  not  be  obtained.  In  99  of  the  latter  number 
symptoms  of  other  antecedent  or  co-existing  tuberculous  lesions  existed. 
In  77  of  the  cases  tuberculosis  in  an  etiological  or  clinical  aspect  was 
present.  Leloir  observed  several  cases  in  which,  after  years,  a  lupus  of 
the  face  gave  ris.e  to  a  pseudo-erj'sipelatous  swelling  of  the  face,  which 
disappeared  after  a  time,  to  be  followed  by  swelling  of  the  submaxillary 
l3'mpliatic  glands,  which  remained  stationar3\  Soon  after  the  aflection 
of  the  lymphatic  glands  had  appeared,  febrile  disturbances,  gastric  S3'mp- 
toms,  and  evidences  of  pulmonary  infiltration  followed.  In  all  of  these 
cases  Leloir  believes  that  the  virus  of  tuberculosis  had  left  the  primary' 
location,  and  had  migrated  through  the  lymphatic  vessels  and  glands  into 
the  lungs.  In  10  out  of  his  17  cases  the  tubercular  nature  of  lupus  was 
clinically  manifest.  Sachs  ascertained  that,  of  105  cases  of  lupus  which 
he  collected,  in  86  per  cent,  the  patients  had  co-existing  tuberculosis  in 
other  parts  of  the  body,  or  a  hereditary  predisposition  to  tuberculosis 
could  be  shown  to  exist. 

Experimental  and  Bacteriological  Evidences  of  the  Tubercular  Nature 
of  Lupus. — If  the  clinical  and  anatomical  proofs  which  have  been 
advanced  to  establish  the  tubercular  nature  of  lupus  point  unequivocally 
in  that  direction,  the  crucial  test  is  furnished  b}^  the  inoculation  experi- 
ments and  liacterioiogical  investigations  that  have  been  made  with  the 
same  object  in  view.  Koch,  in  his  paper  on  the  etiology  of  tuberculosis, 
states  that  he  produced  a  pure  culture  of  the  bacillus  tuberculosis  from 
a  case  of  lupus  which  resembled  in  ever}-  respect  the  cultures  obtained 
from  recognized  tuberculosis,  and  with  the  fifteenth  generation  from  this 
source,  one  3'ear  after  the  first  cultivation,  he  inoculated  5  guinea-pigs 
bv  subcutaneous  injection  and  produced  typical  tuberculosis  in  all  of 
them.  Doutrelepont  found  in  7  cases  of  lupus  tlie  bacillus  tuberculosis 
invarial)l3'  present,  in  greater  or  less  number,  either  within  the  cells  or 
dispersed  in  small  groups  between  them.  He  never  found  them  in  the 
interior  of  giant-cells,  but  in  their  immediate  vicinit3'.  In  a  second 
communication  the  same  author  reports  18  additional  cases  of  lupus,  in 
each  of  which  the  presence  of  the  bacillus  could  be  demonstrated  in  the 
tissues.  Demme  detected  the  bacillus  in  6  cases  of  lupus.  Pfeiffer 
found  it  in  a  case  of  lupus  of  the  conjunctiva.     Schuchardt  and  Krnuse 


462  PRINCIPLES    OF    SURGERY. 

discovered  the  bacillus  in  3  cases  of  lupus  affecting,  respectively',  the 
face,  ears,  and  leg.  In  examinations  made  of  11  cases  of  lupus  by  Cornil 
and  Leloir,  and  4  bv  Koch,  for  the  especial  purpose  of  showing  the 
identity  of  lupus  and  tuberculosis,  the  bacillus  was  found  in  every 
instance.  In  the  artificial  tuberculosis  of  animals,  produced  by  implanta- 
tion of  lupus-tissue,  the  specific  microbe  was  shown  to  exist  by  P:igen- 
stecher,  Pfeiffer,  Koch,  and  Doutrelepont.  To  proA'e  that  lupus  and 
tuberculosis  are  identical,  it  became  necessary  to  furnish  tlie  necessary 
experimental  i)roof,  and  to  show  tlic  uniform  presence  of  the  bacillus  of 
tuberculosis  in  the  lupus-tissue,  all  of  which  has  been  done  with  almost 
infiillible  positive  results.  The  inocuhition  experiments  with  lupus- 
tissue  have  already  been  referred  to,  and  from  them  it  can  be  learned 
that,  with  few  exceptions,  the}'  were  followed  by  positive  results ;  that 
is  to  say,  implantation  of  lupus-tissue  into  subcutaneous  tissue  or  the 
peritoneal  cavity,  in  animals  susceptible  to  tuberculosis,  gave  rise  to 
local  tuberculosis  at  the  point  of  implantation  and  to  dissemination  of 
the  process  in  a  manner  characteristic  of  tuberculosis  in  man.  A  diffuse 
tuberculosis  of  the  skin  and  mucous  membranes,  occurring  as  a  sort  of 
secondar}'  localization  in  patients  suffering  from  advanced  tuberculosis, 
has  been  recently  described  by  Pantlen,  Bizzozero,  Baumgarten,  Chiari, 
Hall,  Janisch,  Riehl,  Vidal,  and  Finger.  As  such  cases  occur  in  conse- 
quence of  auto-infection  in  persons  debilitated  by  the  ravages  of  the 
primary  disease  in  the  lungs,  it  is  not  surprising  that  the  skin  affection 
should  extend  more  rapidly  than  in  cases  of  primary  tuberculosis  of  the 
skin. 

Pathology  and  Morbid  Anatomy. — As  every  case  of  tuberculosis  of 
the  skin  is  caused  l)y  the  entrance  of  tubercle  l)acilli  from  without 
througli  some  infection-atrium,  the  primary'  pathological  changes  occur 
at  the  point  of  inoculation.  As  soon  as  the  bacilli  reach  the  vascular 
layers  of  the  skin,  a  nodule  forms  which  contains  the  histological  ele- 
ments described  in  the  section  on  the  Histology  of  Tubercle.  By  the 
formation  of  new  nodules,  a  more  diffuse  cellular  infiltration  of  the 
tissue  between  them,  the  lesion  tends  to  spread,  and,  by  confluence  of  the 
infiltrated  portions,  a  dense  and  more  or  less  extensive  area  of  nodular 
infiltration  maybe  formed.  If  the  continuit}'  of  the  epidermic  la3'er  of 
tlie  skin  has  been  restored  after  infection  has  occurred,  and  the  cell  pro- 
liferation has  been  abundant,  the  swelling  may  resemble  a  papillomatous 
growth,  and,  on  account  of  the  increased  vascular  supply,  an  excessive 
production  and  exfoliation  of  epidermis  over  the  infiltrated  area  occur. 
Tliese  are  the  cases  of  inoculation-tuberculosis  which  have  been  described 
as  tuberculosis  verrucosa  cutis.  The  nodules  undergo  disintegration 
near  the  centre,  and   the  epidermis  at  a  corresponding  point  becomes 


TrBERCULOSlS    OF    THE    SKIN.  463 

macerated  and  detaclied,  leaving  at  first  a  minute  defect,  which  secretes 
a  serous  fluid. 

As  soon  as  the  underl3Mng  granulation  tissue  has  been  exposed 
to  infection  from  without,  infection  with  pus-microbes  occurs,  and 
the  destruction  of  tissue  is  hastened  b}'  the  suppuration  inflammation 
which  follows,  as  the  granulation  cells  are  rapidly  desti'03^ed  bj''  the 
pus-microbes  and  their  ptomaines,  and  are  eliminated  as  pus-corpi;scles. 
Ulceration  now  takes  the  place  of  the  papillomatous  growths,  and  the 
defect  increases  in  size  as  rapidly  as  granulation  tissue  is  produced  b}' 
the  action  of  the  bacillus  tuberculosis.  New  nodules  are  produced  in 
the  immediate  vicinity  of  the  ulcer,  which  are  again  dissolved  bj'  retro- 
grade tissue  metamorphosis  of  its  cellular  constituents  and  purulent 
liquefaction.  It  is  not  uncommon  to  find,  at  some  places,  efforts  at  repair, 
and  even  partial  cicatrization  and  epidermization  ;  but  the  disease  pursues 
its  relentless  course  in  other  directions,  .and,  after  what  appears  as  health}'^ 
new  tissue,  becomes  again  infected  and  the  process  of  destruction  is 
repeated.  In  some  forms  of  tuberculosis  of  the  skin  the  infection 
remains  superficial,  and  only  the  more  superficial  portions  of  the  skin 
undergo  pathological  changes  characteristic  of  tuberculosis  ;  while  in 
other  cases  the  process  extends  deeper  and  deeper,  until  muscles, 
fascia,  and  bone  are  destroj'ed  b}^  the  disease,  in  the  manner  of  its  exten- 
sion from  tissue  to  tissue  resembling  the  clinical  behavior  of  malignant 
tumors.  In  this  manner  the  whole  nose,  e^yelids,  and  the  greater  portion 
of  the  face  are  frequently*  destro3'ed  before  the  patient  is  relieved  from 
his  sufferings  b}'  a  merciful  death.  Microscopical  examination  shows 
the  lesions  to  consist  in  the  formation  of  granulation  tissue,  in  which 
the  typical  structure  and  histological  elements  of  tubercle  can  be  readily 
recognized.  Caseation  is  seldom  found,  probabl}'  on  account  of  the 
location  of  the  tubercular  product  so  near  the  surface  of  the  skin,  and 
also  because  the  granulation  tissue  soon  becomes  the  seat  of  a  secondary' 
infection  with  microbes  which  prevent  caseation.  Inmost  cases  a  well- 
marked  reticulum  is  present  between  the  new  cells,  and  these  are  often 
groujied  in  masses  around  the  blood-vessels. 

Symptoms  and  Diagnosis. — Tuberculosis  of  the  skin  is  most  fre- 
quently- met  with  in  middle-aged  persons,  but  no  age  is  exempt  from  it, 
as  I  have  seen  it  in  children  5  years  of  age  and  in  persons  far  advanced 
in  3'ears.  It  attacks  most  frequently  the  nose,  ej^elids,  cheeks,  ears,  and 
hands,  but  it  may  also  develop  upon  the  difl'erent  parts  of  the  trunk. 
The  disease  commences  in  the  form  of  a  small,  red,  vascular  nodule ;  is 
not  painful  nor  tender  on  pressure.  In  the  vicinity  of  this  nodule  new 
foci  spring  up,  and  by  confluence  may  form  a  swelling  of  considerable 
size.     To  the  touch  these  nodules  impart  rather  a  sensation  of  elasticity 


464  PRINCIPLES   OF    SURGERY. 

than  hardness,  and  if  the  swelling  is  large  in  size  an  obscure  sense  of 
fluctuation  mi\y  be  felt.  Before  ulceration  takes  place  the  surface  of  the 
nodules  is  covered  by  a  thickened  epidermis,  which  can  be  scraped  off  in 
white  scales.  If  no  ulceration  take  place  (lupus  non-exedens),  the 
nodules  nia}'  remain  stationary  in  size  for  an  indefinite  period  of  time  or 
undergo  a  spontaneous  cure  by  cicatrization,  during  which  the  epithelioid 
cells  are  converted  into  connective  tissue.  Ulceration  begins  over  the 
centre  of  the  nodule,  at  a  point  where  the  nutrition  of  tiie  tissues  is 
most  impaired  by  pressure,  and  extends  from  here  toward  the  margins 
of  the  nodule,  attacking  the  new  nodules  almost  as  fast  as  they  are 
formed  (luj^us  exedens).  Cicatrization  and  ulceration  are  often  seen 
side  by  side.  Ulceration  is  hastened  by  the  secondary  infection  with 
pus-microbes,  whicii  invade  the  granulation  tissue  in  the  margins  of  the 
ulcer,  occupying  the  tubercular  zone.  Repair  b}'  cicatrization  and  epi- 
dermization  is  more  likely  to  occur  if  the  infection  remains  superficial, 
but  is  usually  entirely  absent  as  soon  as  the  tubercular  process  has  ex- 
tended beyond  the  limits  of  the  skin.  The  ditferential  diagnosis  as  to 
tuberculosis  of  the  skin,  tertiary  syphilis,  and  epithelioma  is  generally 
very  diflficult,  and  sometimes  almost  impossible.  There  is  very  little 
difference  between  the  histological  structure  of  a  tubercle-nodule  and  a 
gumma,  and  the  most  experienced  microscopist  is  liable  to  make  a  mis- 
take if  called  upon  to  make  a  diagnosis  exclusively  by  the  use  of  the 
microscope. 

The  histor}'  of  the  case  is  of  the  greatest  importance  in  making  a 
differential  diagnosis  between  tuberculosis  and  syphilis.  If  the  patient 
is  positive  that  he  never  contracted  S3'pliilis,  it  is  still  possible  that  the 
lesion  may  be  S3philitic,  as  the  disease  may  have  been  inherited;  if  he 
give  a  history  of  primarj'^  and  secondary  S3'philis,  the  affection  may 
still  be  tubercular;  but  a  straight  histor}'  of  tuberculosis  or  syphilis  will 
go  far  in  determining  the  nature  of  the  local  affection.  If  any  doubt 
remain,  this  can  be  cleared  up  by  the  use  of  the  microscope  in  the 
course  of  five  weeks,  either  by  the  effect  i)roduced  by  anti-sy])hilitic 
treatment  or  the  result  of  inoculation  experiments  made  by  implantation 
of  fragments  from  the  inflammatory  product  into  the  subcutaneous 
tissue  in  guinea-pigs.  The  microscopic  examination  of  fragments  of 
tissue  removed  for  this  purpose  must  have  in  view  the  detection  of  the 
bacillus  of  tuberculosis,  wdiich  is  constantl}'  present  in  tubercular  tissue. 
The  specimen  must  be  prepared  by  double  staining  according  to  Ehrlich's 
method,  and  if  the  affection  is  tubercuhir,  the  bacillus  can  be  found  b^' 
making  a  patient  search  for  it ;  if  it  is  syphilitic,  it  will,  of  course,  be 
absent.  The  bacilli,  however,  may  be  so  few  that  even  a  careful  search 
of  stained  specimens  may  result  negativeh',  and  in  such  a  case  a  positive 


TUBERCULOSIS    OF    THE    SKIN.  465 

diagnosis  can  often  be  made  by  observing  the  effects  of  a  thorough  anti- 
syphilitic  treatment.  For  an  adult,  ^'g  grain  of  sublimate  with  15  grains 
of  potassic  iodide,  dissolved  in  distilled  water,  is  given  four  times  a  da}-, — 
after  each  meal  and  at  bed-time.  If  the  lesion  is  syphilitic,  a  decided 
improvement  will  be  observed  in  the  course  of  two  or  three  weeks  ;  if 
tubercular,  this  treatment  will  make  no  decided  impression  on  the  local 
lesion.  The  most  reliable  diagnostic  test  in  differentiating  between 
tuberculosis  of  the  skin  and  a  syphilitic  lesion  consists  in  removing, 
under  antiseptic  precautions,  a  fragment  of  granulation  tissue  the  size 
of  a  small  pea,  and  implanting  the  same  into  the  subcutaneous  tissue  of 
a  guinea-pig. 

Tavel  has  been  studying,  in  a  systematic  manner,  the  diagnostic 
value  of  implantations  of  tubercular  material  in  animals,  mainly-  guinea- 
pigs.  He  found  tliat  fragments  of  granulation  tissue,  taken  from  a 
tubercular  product  and  implanted  into  the  subcutaneous  connective 
tissue  in  the  inguinal  region  in  guinea-i)igs,  invarinldy  produces  in  this 
animal  local,  and  later  general,  miliaiy  tuberculosis,  and  death  in  from 
five  to  six  weeks.  The  course  of  the  disease  thus  artificially  produced 
is  typical ;  at  the  point  of  inoculation  a  hard  nodule  appears  first,  the 
result  of  traumatic  response  on  the  part  of  the  tissues  around  the  graft. 
Next,  a  l3-mphatic  gland  becomes  enlarged  in  the  immediate  vicinity  of 
the  inoculation  and  in  the  direction  of  the  lymphatic  stream.  Often  all 
of  the  inguinal  glands  are  infected  successively.  At  a  later  stage  the 
axillary  glands  become  affected  At  the  necropsy  it  was  always  observed 
that,  of  the  internal  organs,  the  spleen  becomes  affected  first,  then  the 
liver  and  lungs,  but  before  death  is  produced  almost  everj'  organ  is  the 
seat  of  miliary  nodules.  When  the  differential  diagnosis  between  tuber- 
culosis and  sj'philis  cannot  be  made  from  a  clinical  study  of  the  case  or 
by  the  use  of  the  microscope,  inoculation  experiments  will  alwa^^s  furnish 
the  desired  information  in  from  three  to  six  weeks.  If  the  lesion  is 
tubercular,  the  infected  guinea-pig  contracts  the  disease,  and  dies  in 
from  five  to  six  weeks  ;  if  it  is  syphilitic,  the  implantation  will  prove 
harmless  and  the  animal  remains  well.  The  differential  diagnosis  be- 
tween tuberculosis  of  the  skin  and  epithelioma  must  be  based  on  the 
primary  location  of  the  pathological  product  and  the  character  of  the 
infdtration.  Tulierculosis  commences  in  the  vascular  portion  of  the 
skin;  hence,  the  primary  nodule  is  sub-epidermal;  while  epithelioma 
starts  in  the  non-vascular  epidermis  and  inliltrates  tiie  deeper  laj'ers  of 
the  skin  later.  The  tultereular  nodule  is  not  hard,  but  somewhat  elastic, 
to  tlie  touch.  The  carcinomatous  infiltration  feels  almost  as  hard  as 
cartilage,  and  forms  a  part  of  the  e[)itlielial  layer  of  the  skin  from  the 
beginning.     A  tul)erculous  ulcer  of  tlie  skin  is  covered  with  flabby  granu- 


466  PRINCirLES   OF    SURGERY. 

Litions,  and  its  margins,  although  infiltrated,  do  not  feel  as  firm  as  the 
borders  of  an  ulcerating  epithelioma.  Under  the  microscope  the  tubercle- 
nodule  shows  granulation  cells  in  the  meshes  of  a  delicate  reticulum, 
while  in  a  section  of  an  epithelioma  a  well-marked  alveolated  reticulum 
can  be  seen,  the  meshes  of  which  are  occupied  by  em])ryonal  epithelial 
cells  arranged  in  concentric  htyers.  Another  microscoi)ic  criterion  is 
the  absence  of  blood-vessels  in  tubercle-nodules,  while  carcinoma  is  a 
vascular  structure. 

Prognosis. — Primary  local  tuberculosis  of  the  skin  may  lead  to 
glandular  infection,  and,  after  the  last  lymi)hatic  filter  has  been  passed, 
to  general  miliary  tuberculosis.  The  tu])ercular  product  in  exceptional 
cases  becomes  the  starting-point  of  carcinoma.  The  local  extension  of 
the  tubercular  process  is  subject  to  many  variations.  In  some  instances 
the  process  commences  during  early  life,  and  remains  stationary  for 
twenty  or  more  years,  when  it  suddenly  commences  to  extend  vei'y  rap- 
idly, destroying  all  of  the  tissues  which  come  in  its  way,  irrespective  of 
their  anatomical  structure.  Tuberculosis  of  the  face,  manifesting  such  a 
tendency  to  rapid  extension,  may  in  a  few  months  destroy  nearly  all  of 
the  soft  tissues  and  a  considerable  portion  of  the  superficial  bones,  so 
that  the  head  looks  more  like  a  skull  than  the  head  of  a  living  being.  In 
other  instances  the  ulceration  keeps  extending,  while  at  otiier  points  the 
healing  process  is  progressing  with  equal  speed.  In  such  cases  the 
massive  scars  are  often  productive  of  the  most  hideous  deformities. 
Recurrence  of  the  disease  in  the  scar-tissue  is  of  common  occurrence. 
The  prognosis,  as  far  as  life  is  concerned,  is  favorable  so  long  as  the 
disease  remains  local  and  does  not  progress  rapidly ;  while  life  is  threat- 
ened as  soon  as  regional  infection  through  the  lymphatic  glands  takes 
place,  or  when  ulceration  extends  rapidl}- without  any  tendency  to  repair 
by  cicatrization  and  epidermization.  Tuberculosis  of  the  skin  without 
ulceration  is  a  more  benign  form  of  the  disease  than  when  ulceration  has 
occurred,  as  in  the  latter  case  the  destructive  process  is  hastened  by 
secondary  infection  with  pus-microbes. 

Treatment. — About  the  only  medicine  that  deserves  any  confidence 
in  the  treatment  of  tuberculosis  of  the  skin  is  o.rsenic.  This  drug  can  be 
given  in  the  form  of  F'owler's  solution,  in  doses  of  from  3  to  10  drops 
after  each  meal,  well  diluted  with  w\ater.  It  is  best  to  commence  with 
the  smallest  dose  and  add  1  drop  every  week  until  the  ph3siological 
effect  is  produced,  when  the  use  of  the  medicine  is  not  suspended,  but 
the  dose  is  diminished.  To  be  of  any  use,  the  medicine  has  to  be  con- 
tinued for  weeks  and  months.  If  the  patient  is  anaemic,  it  is  combined 
with  the  tincture  of  chloride  of  iron,  and,  if  the  patient's  appetite  is  poor, 
with  one  or  more  of  the  bitter  tonics.     If  the  patient  is  emaciated,  pure 


TUBERCULOSIS    OF    THE    SKIN.  467 

codliver-oil  can  be  given  with  good  results  ;in  hour  and  a  half  after  meals, 
in  doses  which  will  be  tolerated  by  the  stomach.  If  digestion  is  impaired 
this  drug  should  be  withheld.  A  well-selected,  nutritious  diet  is  indicated 
in  all  such  cases,  with  plent}-  of  out-door  exercise.  Salt-water  baths  invigo- 
rate the  peripheral  circulation,  nnd  coiisecpiently  favor  the  limitation  of 
the  disease  and  the  process  of  repair.  The  surgical  treatment  of  tuber- 
culosis of  the  skin  is  to  be  conducted  upon  the  same  principles  as  opera- 
tion for  the  removal  of  malignant  tumors.  The  use  of  caustics  often 
does  more  harm  than  good.  The  great  object  of  the  local  treatment  is  to 
remove  every  jMrtivle  of  the  infected  tissues,  for  if  this  is  not  done  a  re- 
currence is  almost  sure  to  take  place.  If  the  patient  object  to  a  radical 
operation,  and  the  tubercular  process  has  gone  on  to  ulceration,  all  irri- 
tating applications  should  be  avoided  and  the  ulcer  protected  b}^  a  piece 
of  lint  spread  with  empl.  h^drargyri  or  nnguent.  hydrargyri  0x3-d.  albi. 
Balsam  of  Peru  can  also  be  used  with  benefit  as  a  local  application.  If  a 
radical  operation  is  decided  upon,  this  should  be  done  preferabl}'  by  ex- 
cision. Excision  should  be  practiced  exclusively  in  cases  where  the 
extent  of  the  disease  is  limited.  The  incision  should  be  made  some 
distance  from  the  visible  margins  of  the  infiltration,  in  order  to  include 
tissues  which,  although  presenting  macroscopicall}'  a  health}^  appearance, 
may  already  be  infected  with  bacilli,  conveyed  there  by  migrating  leu- 
cocytes. The  greatest  care  must  be  exercised  in  removing  the  deeper 
portions  of  the  infiammatory  product,  as  this  may  send  down  projections 
at  diflerent  points  which  it  is  necessar}'  to  remove  with  the  princi^Dal 
mass. 

Thiersch's  method  of  restoring  the  excised  skin  places  the  surgeon 
in  a  position  where  he  can  excise  an  extensiA'e  area  of  tegument,  and  yet 
obtain  primary  healing  of  the  wound  and  perfect  restoration  of  the  skin 
under  a  single  dressing.  I  have,  on  several  occasions,  removed  tuber- 
cular foci  from  the  face  and  temporal  region  the  size  of  the  palm  of  the 
hand,  and,  b}-  covering  the  defect  at  once  with  large  skin-grafts,  saw  the 
whole  healing  process  completed  in  two  weeks,  with  almost  perfect 
restoration  of  the  lost  tissues.  In  cases  where  the  disease  is  too  exten- 
sive for  excision,  removal  of  the  infected  granulations  is  attempted  by 
the  vigorous  use  of  Yolkmann's  sharp  spoon.  Skin-grafting  can  be  done 
after  curetting  in  the  same  manner  as  after  excision,  but  the  knife  always 
leaves  a  better  surface  for  skin-grafting  than  the  sharp  spoon.  If,  after 
either  operation,  the  result  is  not  perfect,  and  the  tubercular  process 
returns  at  one  or  more  points,  the  granulations  are  again  removed  with 
the  sharp  spoon  and  the  defect  covered  with  skin-grafts.  Tuberculosis 
without  ulceration  demands  treatment  bj'  excision,  while  in  the  case  of 
ulcerating  nodules  the  choice  lies  between  the  knife  and  sharp  spoon,  and 


468  PRINCIPLES    OF    SURGERY. 

to  the  first  preference  should  be  given  in  all  cases  Avhere  excision  can  be 
(lone  with  a  fair  prospect  of  removing  all  of  the  infected  tissues.  The 
constitutional  treatment  should  be  continued  for  several  montlis  after  the 
local  lesion  has  apparentl}'  healed,  as  the  disease  is  very  liable  to  recur 
at  the  site  of  operation.  The  site  of  operation  should  bo  carefully  pro- 
tected against  injur}"  a  long  time  after  the  process  of  repair  has  been 
completed,  in  order  to  guard  against  a  return  of  the  disease,  from  local 
irritation  preparing  the  soil  for  the  pathogenic  action  of  latent  bacilli 
which  may  remain  incorporated  in  the  scar-tissue. 


CHAPTER  XIX. 

Tuberculosis  of  Lymphatic  Glands  and  Peritoneum. 

tuberculosis  of  lymphatic  glands. 

That  most  cases  of  cluoiiic  inflammation  of  tlie  lymphatic  glands 
are  in  their  origin,  course,  and  final  termination  instances  of  local  tuber- 
culosis, has  been  satisfactorily  shown  by  clinical  experience,  microscopic 
examination,  inoculation,  and  cultivation  experiments. 

Manner  of  Infection  and  Dissemination  of  the  Bacillus  of  Tuber- 
culosis.— The  tubercle  bacilli  enter  the  lymphatic  circulation  through 
some  abrasion  or  pathological  defect  of  the  skin  or  mucous  surface ;  any 
loss  of  continuity  of  surface  may  furnish  the  necessary  portio  invasionis 
for  the  entrance  of  the  microbes  from  without.  In  tubercular  ail'ections 
of  the  skin  the  point  of  inoculation  becomes  the  centre  of  the  primary 
nodule,  because  the  bacilli  are  present  in  sufficient  quantity  and  viru- 
lence to  produce  the  necessary  irritation  ;  but  in  tuberculosis  of  the  lym- 
phatic glands  the  microbes  enter  the  lymphatic  channels  usually  before 
the}'  have  caused  any  visible  lesions  at  the  point  of  entrance. 

Yolkmann  found  tubercle  bacilli  in  tiie  skin  of  an  eczematous  fore- 
arm, and  it  is  probable  that  many  cases  of  tuberculosis  of  the  cervical 
glands  in  children  are  caused  b}*  the  entrance  of  tubercle  bacilli  through 
an  eczematous  patch  on  the  face,  ear,  or  scalp.  In  perhaps  95  out  of 
every  100  cases  of  tuberculosis  of  the  lymphatic  glands  the  disease  at- 
tacks the  glands  of  the  neck, — as  the  scalp,  face,  and  mouth  are  parts  of 
the  body  most  frequentl}-  the  seat  of  slight  injuries  and  superficial 
lesions,  and  also  most  exposed  to  tubercular  infection.  The  lymphatic 
glands  act  as  filters  for  the  microbes  which  enter  the  body  through  the 
l3'mphatic  channels.  The  pathological  conditions  which  are  produced  in 
the  interior  of  a  lymphatic  gland  by  the  presence  of  pathogenic  micrO' 
organisms  are  well  calculated,  for  the  time  being  at  least,  to  limit  the 
extension  of  the  infection.  The  lymphadenitis  which  is  produced  blocks 
the  lymph-spaces  with  the  products  of  a  specific  inflammation,  which, 
temporarily  at  least,  mechanicall}-  obstructs  the  way  for  the  microbes 
toward  the  general  circulation.  Primary  infection  of  a  l^'mphatic  gland 
by  the  bacillus  of  tul)erculosis  in  many  instances  attacks  diff"erent  por- 
tions of  the  gland  from  the  very  beginning,  as  a  number  of  independent 

(469) 


470  PRINCIPLES    OF    SUKGKRY. 

centres  of  tissue  proliferation  are  established  around  each  microbe,  or 
around  each  colony-  of  microbes  arrested  on  their  way  through  the 
gland.  These  separate  nodules  soon  become  confluent  and  form  a  mass 
of  considerable  size,  which  soon  implicates  the  entire  parenclijma  of  the 
gland.  Local  dissemination  of  the  bacillus  of  tuberculosis  in  the  in- 
terior of  the  gland  is  accomplished  l)y  the  assistance  of  the  lymph- 
stream,  as  long  as  the  microbes  remain  free,  and  through  the  medium 
of  wandering  cells  as  they  have  become  attached  to  or  have  entered  the 
protoplasm  of  the  lymphoid  corpuscles  and  leucocytes. 

Regional  infection  is  not  limited  to  the  lymphatic  glands,  on  the 
proximal  side  of  the  primary  focus,  as  during  the  course  of  the  disease 
we  often  observe  that  lymph-glands  become  involved  whicli  are  not  in  the 
direct  course  of  the  lympli-stream.  As  tlie  bacillus  of  tuberculosis  is 
non-motile,  we  can  onl}'  explain  its  transportation  in  a  direction  opposite 
the  lymph-current  b}'  its  conveyance  in  such  a  direction  b^^  migrating 
amoeboid  cells.  As  the  lymph-stream  is  impeded  or  perhaps  completely 
arrested  by  the  inflammatory  product  which  has  accumulated  in  the 
lymph-spaces,  migration  of  leucoc^'tes  in  an  opposite  direction  is  easily 
explained.  The  usual  course  of  infection  along  the  lymphatic  channels  is, 
however,  in  the  direction  of  the  lymph-current.  The  course  of  the  disease 
is  almost  characteristic.  A  l^'mphatic  gland  in  the  submaxillary  or  parotid 
region  becomes  enlarged,  and  from  this  centre  the  infection  invades  suc- 
cessively gland  after  gland,  until  the  whole  chain  of  lymphatics  from  the 
angle  of  the  lower  jaw  to  the  clavicle  has  become  involved.  Another 
interesting  feature  is  observed  in  reference  to  the  regional  diffusion  of 
the  tubercular  process,  as  the  course  of  infection  usually  corresponds 
to  the  location  of  the  gland  first  affected.  If  the  infection  has  involved 
primaril}^  one  of  the  deep  glands  of  the  neck,  the  glands  subsequently 
invaded  belong  to  the  deep  lymphatics  which  follow  the  larger  blood- 
vessels of  the  neck.  If,  on  the  other  hand,  the  primar}^  depot  is  located 
in  one  of  the  superficial  glands,  the  glands,  which  are  being  irrigated  by' 
the  lymph  that  flows  through  and  from  the  gland,  become  the  seat  of 
successive  infection,  showing  again  that  regional  infection  nsually  takes 
place  in  the  direction  of  the  lymph-current.  In  extensive  tuberculosis 
of  the  glands  of  the  neck,  the  superficial  and  deep  glands  are  affected  at 
the  same  time,  the  infection  from  one  set  of  vessels  to  the  other  being 
accomplished  through  the  medium  of  communicating  branches.  As  long 
as  the  infection  has  not  extended  along  the  entire  length  of  the  chain 
of  lymphatic  glands,  the  patient  is  protected  against  miliar}'  tuberculosis  ; 
but  as  soon  as  the  virus  has  passed  all  of  the  lympliatic  filters  it  enters 
the  general  circulation,  and  diflfuse  miliary  tuberculosis  follows  as  an 
inevitable  result. 


TUBERCULOSIS   OF    LYMPHATIC    GLANDS.  4:71 

Pathological  Histology  and  Morbid  Anatomy. — As  soon  as  a  sufficient 
number  of  bacilli  lias  entered  tlie  parencli>  ma  of  a  lymphatic  gland,  a 
karj'okinetic  process  is  initiated  wliich  involves  the  parenchyma-cells,  the 
cells  of  the  reticulum,  and  the  endothelial  cells.  The  proliferating  tissue- 
cells  produce  epitheloid  and  giant  cells,  -svhile  the  lymphoid  elements  are 
either  the  normal  lymphoid  corpuscles,  ^vhich  have  remained  unatiected 
by  the  inflammatory-  process,  or  leucocytes.  As  the  number  of  bacilli 
present  is  not  great,  the  process  is  a  very  slow  one,  and  the  inflamma- 
torj'  product  undergoes  very  gradually  the  characteristic  degenerative 
changes.  The  entrance  of  new  bacilli  from  the  infection-atrium  is  pre- 
vented b}'  the  obstruction  in  the  lymph-spaces,  caused  by  the  accumula- 
tion within  them  of  the  products  of  inflammation,  which  arrests  the 
lymphatic  circulalion  in  the  afferent  vessels  of  the  gland,  through  which 
primarily  the  bacilli  entered.  The  bacilli  found  in  the  tubercular  gland 
are,  therefore,  derived  from  the  multiplication  of  the  bacilli  which  origi- 
nall3'^  entered  the  gland  from  the  primary  infection-atrium.  The  cells  that 
first  undergo  coagulation  necrosis  are  those  in  the  centre  of  each  nodule, 
for  reasons  which  have  been  previously  mentioned.  As  the  products  of 
coagulation  necrosis  do  not  furnish  the  necessary  nutritive  material  for 
the  growth  of  the  bacillus,  the  microbes  gradually  disappear  in  the  centre 
of  the  nodule,  while  they  can  still  be  found  within  and  between  the  cells  in 
the  surrounding  granulation  tissue.  Cell  necrosis  is  followed  by  caseation, 
and  by  this  time  nearly  all  of  the  bacilli  have  disappeared,  but  inoculation 
experiments  with  cheesy  material  have  shown  that  spores  remain  in  an 
active  condition,  and  capable  of  reproducing  the  disease  in  animals.  The 
numerous  nodules  which  appear,  often  almost  simultaneously,  in  the  in- 
terior of  the  same  gland  become  confluent,  and  in  the  course  of  time  the 
entire  parenchyma  of  the  gland  is  destroyed,  while  the  intact  capsule  of 
the  organ  still  furnishes  a  v/all  of  protection  against  infection  for  the 
surrounding  tissue.  A  single  tubercular  gland  is  seldom  larger  than  a 
walnut,  and  the  large  masses  found  in  the  neck  and  other  regions  are 
composed  of  several  glands  so  closely  packed  together  as  to  give  the 
appearance  of  a  single  gland.  When  the  capsule  becomes  infected,  the 
same  processes  are  initiated  here  as  in  the  parenchyma  of  the  gland  ;  the 
connective  tissue  is  transformed  into  granulation  tissue,  which  undergoes 
coagulation  necrosis  and  caseation  in  the  same  manner  as  the  fixed  tissue- 
cells  of  the  i)arenchyma;  and,  finally,  after  perforation  of  the  capsule  has 
taken  place,  the  inflammation  extends  to  the  paraglandular  tissues,  re- 
sulting in  tubercular  periadenitis.  The  cheesy  material  ma}-  dry  and 
shrink  and  become  inclosed  b}-  a  capsule  of  dense  connective  tissue, 
resulting  in  calcification  ;  or  it  undergoes  liquefaction.  If  secondary 
infection  with  pus-microbes  take  olace,  a  not  infrec^uent  occurrence  in 


472  PRINCIPLES    OF    SURGERY. 

tuberculosis  of  the  gltinds  of  the  neck,  :ui  acute  suppurative  iullamuiation 
takes  the  place  of  the  chronic  process,  and  almost  without  exception  re- 
sults in  a  rapi(ll3--spreading-  suppurative  [)eri;ulenitis.  The  connective 
tissue  surrounding  tlie  gland  becomes  sw^ollen  and  (jL'dcmatous  and  large 
abscesses  form,  which,  on  being  incised,  give  exit  to  pus  whicli  resembles 
the  pus  of  an  ordinary  phlegmonous  inflammation.  The  suppurative  in- 
flammation results  in  extensive  detachment  of  the  cheesy  glands,  which 
at  this  time  can  be  readily  enucleated  b}'  the  linger.  If,  however,  the  ab- 
scess is  simpl}'  incised,  and  the  radical  operation  postponed  for  weeks  or 
months,  the  removal  of  such  glands  is  an  exceedingly-  difficult  task, 
as  the  capsule  of  the  gland  will  then  be  found  intimately  adherent 
throughout  the  surrounding  tissues. 

Symptoms  and  Diagnosis. — Tuberculosis  of  the  lyniphatic  glands 
occurs  most  frequently  in  persons  between  15  and  30  years  of  age.  The 
regions  most  frequently  affected  are  the  cervical,  parotid,  sul)maxillary, 
axillar3^,  and  inguinal.  Tuberculosis  of  the  parotid,  submaxillary,  and 
cervical  h'mpliatic  glands  is  often  preceded  by  eczema  of  the  scalp,  ears, 
or  face,  or  by  a  catarrhal  or  tubercular  inflammation  of  the  mucous  mem- 
brane lining  tlie  nose  and  pharynx.  It  is  possible  that  in  many  of  these 
cases  the  catarrhal  inflammation  creates  the  necessar}-  infection-atrium 
for  the  entrance  of  the  bacilli  into  the  lymphatic  channels ;  or,  what  is 
more  probable,  that  which  has  been  regarded  as  a  catarrhal  inflammation 
is,  in  reality,  a  mild  tu])ercular  inflammation  that  may  disappear  after 
infection  of  the  lymphatic  glands  has  occurred.  In  the  region  of  the 
neck,  the  first  glands  affected  are  usually  the  submaxillary,  or  the  glands 
just  behind,  in  front,  or  below  the  external  meatus.  Progi-essive  infec- 
tion is  the  most  characteristic  clinical  feature  of  tuberculosis  of  the 
lymphatic  glands.  Regional  infection,  as  has  been  stated,  usually  takes 
place  by  the  extension  of  the  disease  from  gland  to  gland,  until  the  whole 
chain  in  a  region  has  become  aftected.  In  a  case  far  advanced,  for  in- 
stance, the  glands  first  affected  may  l)e  as  large  as  a  walnut;  their  size 
then  gradually  diminishes,  so  that  those  last  infected  may  not  be  larger 
than  a  split  pea.  The  degenerative  changes  are  also  most  marked  in  the 
glands  first  affected;  so  that,  while  the  primary  foci  show-  well-marked 
evidences  of  caseation,  and  caseation  with  liquefaction,  the  glands  last 
infected  still  present  a  normal  pinkish  color.  The  number  of  glands 
affected  in  one  region  varies  from  one  to  twent}'  or  more.  If  many 
glands  are  affected,  the  hyperplastic  inflammation  in  their  periphery'' 
usually  results  in  their  becoming  matted  together  into  a  dense  nodular 
mass.  With  the  exception  of  the  neck,  it  is  seldom  that  more  than  one 
anatomical  region  is  affected.  In  the  cervical  region  it  is  not  uncommon 
to  find  the  glands  on  both  sides  affected  at  the  same  time.     The  infected 


TUBEKCULOSIS    OF    LYMPHATIC    GLANDS.  -473 

glands  increase  gradually  in  size  ;  the}'  are  painless  and  not  tender  on 
pressure.  At  first  they  are  movable,  and  appear  loosely  attached  to  the 
surrounding  tissues.  With  the  a[)pearance  of  periadenitis  the  swelling 
rapidly  increases  in  size,  and  the  gland  becomes  fixed  and  immovable. 
Liquefaction  of  the  cheesy  material  is  announced  b}^  softening  and  per- 
ceptible fluctuation.  Secondary  infection  with  pyogenic  microbes  is 
followed  by  phlegmonous  inflammation  in  the  capsules  and  in  the  connec- 
tive tissue  surrounding  the  affected  glands.  The  course  of  the  disease, 
so  far  as  time  is  concerned,  is  extremely  variable.  The  extension  of  the 
infection  and  the  growth  of  the  swellings  may  become  arrested  for 
months  or3e:irs,  when  the  disease  may  take  a  new  start  and  pursue  its 
t^'pical  course.  I  recollect  the  case  of  a  woman,  45  years  of  age,  who 
had  an  enlarged  gland  the  size  of  a  hazel-nut  in  the  upper  cervical  legion, 
which  remained  stationary  for  twenty  years,  when  the  swelling  rapidly 
increased  in  size  ;  new  glands  became  infected,  and,  when  the  glands  were 
removed  b^^  operation,  it  was  seen  that  the  first  gland  was  composed  of 
a  thickened  capsule,  distended  to  its  utmost  b}'  inspissated  cheesy  ma- 
terial. The  capsule  showed  evidences  of  recent  tubercular  inflammation, 
and  small  foci  of  caseation  were  detected  in  the  glands  that  had  recently- 
become  infected.  When  a  true  sui)puration  takes  place  in  a  tubercular 
lymphatic  gland,  it  does  so  in  consequence  of  a  secondary  infection  with 
pyogenic  micro-organisms.  A  spontaneous  and  permanent  cure  is  not 
infrequently  effected  by  the  substitution  of  an  acute  suppurative  process 
in  place  of  the  prinuiry  specific  chronic  inflammation,  which  destroys  the 
entire  soil  of  the  bacillus  tuberculosis  and,  at  the  same  time,  effects  com- 
l)Iete  elimination  of  the  bacilli  through  the  discharges  of  the  abscess. 
While  tuberculosis  of  the  lymphatic  glands  often  stands  in  a  direct  causa- 
tive relationship  to  and  precedes  general,  diffuse,  and  pulmonary  tuber- 
culosis, it  is  seldom  observed  as  a  secondar}'  affection  in  the  course  of 
pulmonary  tuberculosis.  I  have  observed  one  case  of  tul)erenl()sis  of 
the  lungs  with  secondary  infection  of  the  lymphatic  glands.  The  i)atient 
was  a  woman,  50  years  of  age,  who  had  suffered  for  two  years  from  well- 
marked  t\'pical  tuberculosis  of  the  lungs,  when  the  glands  on  both  sides 
of  the  neck  became  infected,  and  continued  to  increase  in  numl)erand  in 
size  until  she  died,  six  months  later.  Frankel  reports  an  interesting  case 
ill  which  lymijhatic  and  pulnuMiary  tuberculosis  developed  almost  simul- 
taneously. Tiie  patient  was  a  woman,  51  years  of  age,  who  had  given 
birth  to  two  children,  their  father  being  the  subject  of  advanced  tuber- 
culosis, and  both  of  whom  died  of  tuberculosis.  She  had  been  in  perfect 
health  until  her  49th  3"ear,  when  she  was  attacked  simultaneously  with 
pulmonary  and  glandular  tuberculosis,  from  the  continued  effects  of 
which  she  died  in  a  few  months.     In  exceptional  cases  glandular  tuber- 


47-4  PRINCIPLES    OF    SURGERY. 

ciilosis  pursues  an  acute  course.  Delafield  reports  an  exceedingly  inter- 
esting case  of  this  kind.  The  disease  coninienced  with  enlargement  of 
one  of  the  cervical  glands  near  the  angle  of  the  lower  jaw,  with  a  tem- 
perature of  40'^  C.  (104^^  F.),  and  rapid  extension  to  the  proximal  glands 
as  far  as  the  clavicle.  Symptoms  of  pulmonary  comi)lication  were  not 
present.  Rapid  emaciation  and  marked  anjumia  supervened,  followed 
after  six  weeks  l)y  swelling  of  axillary  and  inguinal  glands.  Ophthalmic 
examination  revealed  the  same  conditions  of  retina  and  papilla  as  in 
leucaemia  or  Bright's  disease.  A  few  days  after  the  beginning  of  the 
disease  profuse  diarrhoea  and  reduction  to  nearly  normal  temperature 
occurred.  The  diagnosis  was  between  malignant  lymphoma  and  tuber- 
cular adenitis.  During  the  further  course  of  the  disease  bronchial 
breathing  in  both  lungs  appeared.  Heart,  liver,  and  spleen  appeared  to 
be  normal.  Urine  normal,  but  increase  of  temperature  and  respirations 
took  place  during  this  time.  Death  occurred  in  less  than  five  months. 
At  the  autopsy  the  lungs  wei'e  found  congested  and  (Edematous,  with  red 
hepatization  of  the  lower  lobes  and  a  few  miliary  tubercles.  The  spleen 
contained  many  miliary  tubercles  the  size  of  the  head  of  a  pin,  and  most 
of  them  in  a  state  of  cheesy  degeneration.  The  mesenteric  glands  were 
much  enlarged,  and  a  few  of  them  in  a  condition  of  cheesy  degeneration 
and  calcification.  In  the  cheesy  matter  bacilli  were  found.  All  the  cer- 
vical glands  were  affected  with  softening  and  cheesy  degeneration  in  the 
centre.  The  calcification  of  mesenteric  glands  pointed  to  an  earlier 
affection.  The  disease  remained  latent  and  recurred  in  the  same  glands, 
and,  later,  extended  to  the  cervical  glands.  This  case  resembles  the  cases 
described  by  Hilton-Fagge  and  Pj^e-Smith. 

In  reference  to  the  dissemination  in  cases  of  acute  miliary  tuber- 
culosis, Weigert  has  pointed  out  that  in  some  cases  the  bacilli  are  con- 
veyed through  the  lymphatic  system  successively  until  they  reach  the 
general  circulation,  while  in  others,  and  by  far  the  greater  number, 
generalization  of  the  tuberculous  process  takes  place  more  directly  by 
the  entrance  of  tubercular  products  through  a  vein, — an  occurrence  which 
is  followed  at  once  bj*  rapid  and  extensive  diffusion  by  embolic  processes  ; 
when  the  bacilli  have  reached  the  sj^stemic  circulation,  the  intensity  of 
symptoms  and  subsequent  course  of  the  disease  depend  on  the  number 
of  bacilli  which  the  blood  contains.  As  regards  the  frequenc}^  of 
secondary  infection  of  the  lungs  in  cases  of  glandular  tuberculosis, 
Frankel  found  it  present  in  only  18  out  of  148  cases.  In  making  a 
differential  diagnosis  it  becomes  necessary  to  distinguish  tubercular 
adenitis  from  simple  adenitis,  suppurative  adenitis,  syphilitic  adenitis, 
carcinoma,  lymphoma,  lympho-sarcoma,  and  pseudo-leucfemia. 

Simple  adenitis  is  the   result  of  the  entrance  into  the  lymphatic 


TUBERCULOSIS    OF    LYMPHATIC   GLANDS.  475 

circulation  of  iioxjv  that  neither  produce  suppuration  nur  the  Ibrnuilion 
of  new  tissue.  A  number  of  glands  corresponding  to  the  direction  of 
the  lymph-current  from  the  infection-ntriiim.  through  \vhich  the  irritant 
gained  entrance,  enlarge,  but  tlie  inflamniator}'  swelling  subsides  shortly 
after  the  cessation  of  the  primar\-  cause,  with  perfect  restoration  of  the 
structure  and  function  of  tlie  atfected  glands.  Suppurative  adenitis  is  an 
acute  affection  which  terminates  in  the  formation  of  pus  in  a  few  days. 
Syphilitic  adenitis  developing  in  the  course  of  a  primary  syphilitic  sore 
only  attacks  the  glands  contaminated  with  lymph  coming  from  the  infected 
area.  The  adenitis  which  accompanies  secondary  and  tertiary  syphilis 
is  not  limited  to  a  single  region  ;  nearly  all  of  the  external  Ijanphatic 
glands  are  more  or  less  enlarged,  but  especially  those  in  the  occipital 
and  cubital  regions.  Carcinonia  never  occurs  as  a  primary-  lesion  in  the 
l3'mphatic  glands,  and  when  regional  infection  has  occurred  it  is  not 
difficult  to  locate  the  primary  tumor.  Lymphoma  is  a  benign  tumor  of 
the  lymphatic  glands,  and  as  such  is  always  met  with  as  a  single  tumor. 
Lymplio-sarcoma  represents  the  primary  malignant  tumor  of  the  lym- 
phatic glands,  and  gives  rise  to  regional  and  general  infection,  the  infec- 
tion in  these  respects  resembling  the  clinical  tendencies  of  tubercular 
adenitis.  Lj-mpho-sarcoma,  however,  is  a  tumor,  not  an  inflammatory 
swelling,  and,  consequently,  the  tissues  of  which  it  is  composed  do  not 
undergo  degeneration  and  necrosis  at  such  an  earh'  stage,  and  the  rapid 
tissue  increase  leads  to  the  formation  of  large  tumors,  wdiile  tubercular 
glands  the  size  of  an  almond  contain  cheesy  material.  The  unlimited 
growth  which  characterizes  sarcoma  is  cheeked  in  the  tubercular  glands 
by  necrosis  of  the  cells  which  compose  tlie  swelling.  In  pseudo-leuc»mia 
the  fixed  tissue-cells  of  the  parenchyma  of  the  glands  proliferate  b}' 
being  acted  upon  by  a  microbe  as  yet  unknown  ;  but  this  microbe,  unlike 
the  bacillus  of  tuberculosis,  is  diffused  more  extensivelj-  through  the 
lymphatic  system,  involving  one  region  after  another  luitil,  after  the 
disease  has  been  once  well  developed,  almost  every  lymphatic  gland  in 
the  body  has  become  infected.  The  supposed  microbe  of  pseudo- 
leucaemia  possesses  the  property  of  producing  new  tissue  by  its  action 
upon  the  fixed  cells,  but  the  ncAV  product  does  not  undergo  caseation. 
As  the  last  and  infallible  diagnostic  measures,  must  be  mentioned  the 
search  for  the  bacillus  of  tuberculosis  by  the  use  of  the  microscope  and 
inoculation  ex[ieriments. 

Prognosis. — A  tubercular  lymphatic  gland  is  alwa3's  a  source  of 
danger.  Even  if  the  disease  becomes  latent,  a  recurrence  may  take  place 
at  any  time,  and  lead  to  rapid  regional  and  general  infection,  or  general 
infection  may  take  place  directly-  from  an  old  cheesy  focus  by  the 
entrance  of  bacilli  or  their  spores  into  a  vein.     The  prognosis  is  very 


476  PRINCIPLES   OF    SURGERY. 

grave  if  the  patient  is  ana,'inic,  and  the  glands  on  both  sides  of  the  neck 
are  aflected  at  the  same  time.  Friinkel  estimates  the  average  duration 
of  the  disease  from  tiiree  to  four  years.  In  the  eases  whicli  lie  collected 
the  shortest  time  was  two  months  and  the  longest  thirty  3'ears.  Sooner 
or  later,  pulmonary  or  diffuse  general  tuberculosis  is  almost  sure  to  take 
place.  A  spontaneous  cure  is  possible  if  secondar3'  infection  occur  in 
cases  whore  onl}'  a  few  of  the  glands  have  become  infected,  and  suppu- 
ration results  in  the  elimination  of  all  the  infected  tissue.  Suppuration 
only  hastens  a  fatal  termination  if  many  glands  are  affected. 

Treatment. — As  primary  lymphatic  tuberculosis,  in  most  inf-tances, 
signifies  the  entrance  of  bacilli  through  a  loss  of  continuity  of  tiie  skin 
or  a  mucous  membrane,  or  through  the  socket  of  a  carious  tooth,  locali- 
zation occurring  in  one  of  the  nearest  glands  to  the  portio  invasionis,  it 
must  be  regarded  primarily  as  a  local  process  amenable  to  timely  surgi- 
cal treatment.  The  capsule  of  the  lymphatic  glands  constitutes  a  very 
efficient  barrier  against  infection  of  the  paraglandular  tissue  for  a  long 
time,  and  perforation  of  the  capsule  can  only  take  place  after  the  disease 
has  made  considerable  progress,  and  has  been  followed  by  extensive 
caseation  and  especially  by  suppuration.  Early  operative  interference 
is  as  necessary  in  the  treatment  of  tubercular  adenitis  as  in  the  treatment 
of  malignant  tumors,  and  holds  out  more  encouragement,  so  far  as  a  pier- 
manent  cure  is  concerned,  ^y  a  thorough  removal  of  the  primary  foci 
of  infection,  successive  infection  of  proximal  glands  and  general  miliary 
tuberculosis  are  prevented  almost  to  a  certaint}^  if  the  operation  is  per- 
formed before  the  disease  has  extended  beyond  the  capsule  of  the  glands. 
If  the  operation  is  done  at  such  a  favoral)le  time  it  is  not  attended  by 
any  great  difficulties,  as  the  glands  can  be  readily  enucleated,  and,  as 
suppuration  has  not  taken  place,  the  wound  usually  heals  by  primary 
intention.  If,  however,  the  tubercular  inflammation  has  involved  many 
glands,  and  has  extended  to  the  connective  tissue  surrounding  them,  the 
operation  becomes  one  of  the  most  formidable  in  surgery,  on  account  of 
the  close  proximity  of  important  vessels  that  are  often  imbedded  in  the 
mass.  Under  such  circumstances  complete  removal  is  frequently  impos- 
sible and  earl}'  local  recidivation  is  inevitable,  owing  to  imperfect  re- 
moval of  the  primary  microl)ic  cause.  Traumatic  dissemination  is  very 
likely  to  follow  all  imperfect  operations  in  which  portions  of  glands  or 
infected  capsules  are  left  behind,  as  the  operation  wounds  are  inoculated 
witli  bacilli  liberated  during  the  operation.  I  have  seen  in  a  number  of 
such  cases,  as  early  as  a  week  after  the  oi)eration,  the  entire  surface  of 
the  wound  covered  l\y  a  thick  layer  of  granulation  tissue,  whicli  showed 
all  the  histological  evidences  and  possessed  all  the  bacteriological  prop- 
erties of  tubercular  tissue.     As  a  testimony  in   favor  of  the  operative 


TUBERCULOSIS    OF    LY.MI'HATIC    GLANDS.  4  77 

treatment  of  tubercular  adenitis,  I  will  quote  from  the  paper  of  Schuell, 
who  collected  56  cases  of  tuberculosis  of  the  cervical  glands  that  were 
treated  by  extirpation  in  the  clinic  at  Bonn.  In  37  of  these  cases  he  was 
able  to  learn  the  ultimate  result.  In  57  per  cent,  the  operation  was  fol- 
lowed b}-  complete  recovery,  in  27  per  cent,  the  disease  returned  at  the 
site  of  operation,  and  in  i  cases  death  resulted  from  pulmonary  tubercu- 
losis. The  largest  number  of  cases  were  patients  between  10  and  20 
3'ears  of  age. 

FrJiukel  reports  128  cases  operated  upon  by  Billroth,  some  of  the 
operations  being  quite  serious  ;  in  16  cases  the  internal  jugular  vein  had 
to  be  tied.  In  91  of  the  operations  the  wound  healed  b}'  primar}-  union, 
and  in  25  the  healing  was  retarded  by  suppuration.  Erj-sipelas  compli- 
cated the  result  five  times.  In  one  of  these  cases  a  large  part  of  the  tuber- 
cular mass  was  left,  and  it  was  noticed  that  the  erysipelas  had  no  effect 
on  the  tubercular  process.  Only  in  49  of  the  cases  operated  on  coiild 
the  final  result  be  obtained.  Taking  three  and  a  half  years  as  the  time 
when  the  patient  could  be  considered  exempt  from  a  recurrence  of  the 
disease,  it  was  ascertained  that  in  24  per  cent,  no  relapse  followed  the 
operation,  a  local  relapse  was  observed  in  14  percent.,  and  re-appearance 
of  the  disease  distant  from  the  seat  of  operation  in  4  per  cent.  The 
results  of  operation  for  tuberculosis  of  the  Ij'mphatic  glands  have  shown 
the  necessity  of  earl}'  operating,  as  dela}^  renders  the  operation  more 
difficult,  on  account  of  the  progressive  regional  dissemination  of  the  dis- 
ease and  the  occurrence  of  pathological  changes  within  and  around  the 
affected  glands,  which  render  their  complete  removal  more  diflicult ; 
while  at  tlie  same  time  the  danger  of  general  infection  increases  with 
the  local  extension  of  the  disease.  If  the  glands  have  suppurated,  or  if 
the  capsule  has  become  perforated  and  tubercular  periadenitis  or  sup- 
purative periadenitis  has  taken  place,  and  many  glands  are  simultane- 
ously affected,  it  ma^'  not  be  advisable  to  resort  to  excision,  as  Avhen 
extensive  connective-tissue  infiltration  is  present  it  would  be  almost 
Impossible  to  remove  all  of  the  infected  tissues. 

In  such  cases  free  incisions  should  be  made,  and  the  tubercular 
product  be  removed  with  a  Volkmann  spoon.  The  proximal  glands 
which  have  not  undergone  such  extensive  secondary-  pathological  changes 
can  be  excised.  The  scraped  surface  is  freely  iodoforniized  and  the 
wounds  are  sutured  and  drained.  In  removing  the  glands  of  the  neck  it 
is  always  important  to  expose  the  infected  area  b}'  a  large  incision.  The 
operator  should  not  only  feel,  but  see,  every  gland  he  removes.  Accidents 
are  more  liable  to  happen  b}'  removing  the  glands  through  a  small  than 
a  large  incision.  As  in  cases  of  secondary  carcinoma  of  the  lymphatic 
glands  the  extent  of  the  disease  is  onl}-  ascertained  after  incision,  so  in 


47S  PHFNTIPLES    OF    SURGEHY. 

glandular  tuberculosis  the  extent  of  the  aion  of  infection  can  only  be 
ascerlained  after  the  external  incision  is  made.  Whole  chains  of  small 
iilands  which  could  not  be  felt  through  the  skin  are  then  exposed.  In 
tuberculosis  of  the  glands  of  the  neck  the  region  between  the  mastoid 
process  and  the  angle  of  the  lower  jaw  is  almost  always  the  primary  seat 
of  infection.  From  here  either  the  chain  of  glands  behind  the  sterno- 
cleido-mastoid  muscle  or  the  deep  glands  wliich  follow  the  sheath  of  the 
large  vessels  of  the  neck  are  affected,  or  the  superficial  and  deep  lym- 
phatics are  affected  simultaneously.  It  has  been  my  custom  to  expose 
the  glands  occupying  the  upper  region  of  the  neck  by  a  transverse  in- 
cision, extending  from  the  tip  of  the  mastoid  process  of  the  temporal 
bone  to  the  lower  angle  of  the  jaw,  and  from  there  along  the  lower  border 
of  the  bone,  as  far  as  the  disease  extends  in  the  submaxillary  region. 
This  incision  is  joined  by  another,  extending  from  the  angle  of  the  lower 
jaw  either  along  the  anterior  border  of  the  sterno-cleido-mastoid  muscle 
as  far  as  its  sternal  insertion,  if  the  deep  glands  are  to  be  removed,  or,  if 
the  posterior  superficial  set  of  glands  are  affected,  it  is  carried  in  a  down- 
ward and  backward  direction,  following  the  chain  of  enlarged  glands.  If 
the  latter  incision  is  selected,  the  external  jugular  vein  is  divided  between 
two  ligatures.  The  ])latysma  niyoides  muscle  is  divided  throughout  the 
whole  length  of  the  incision  before  an  attempt  is  made  to  remove  any  of 
the  glands.  The  siu-geon  should  aim  to  remove^  as  nearly  as  he  can,  all 
of  the  infected  glands  in  one  disconnected  string.  In  many  cases  one  or 
two  tubercular  glands  will  be  found  imbedded  in  the  lower  portion  of 
the  parotid  gland,  and  very  frequently  also  in  the  submaxillar^'  salivary 
gland.  If  the  tubercular  glands,  with  their  capsules,  can  be  enucleated, 
this  should  be  done ;  but  if  this  is  impossible,  it  is  better  to  remove  the 
lower  portion  of  the  parotid  with  them  in  preference  to  leaving  any 
infected  tissue  behind.  Under  the  same  circumstances  I  prefer  to  ex- 
tirpate the  submaxillary  gland  in  foto.  If  the  deep  glands  of  the  neck 
must  be  removed,  it  is  absolutely  necessary  to  divide  the  sterno-cleido- 
mastoid  muscle  near  its  centre,  and  then  reflect  both  ends  nearlj^  as  far 
as  the  origin  and  insertion  of  the  muscle,  which  freely  exposes  not  only 
the  affected  glands,  but  also  the  important  structures  of  the  neck,  which 
it  is  important  to  avoid  in  the  dissection.  The  dissection  must  always 
be  made  with  the  greatest  care,  and  in  the  vicinity  of  the  large  vessels 
every  structure  must  be  identified  before  it  is  separated.  The  finger  and 
blunt-pointed,  curved  scissors  are  the  most  important  instruments  in 
making  the  deep  dissection.  The  internal  jugular  vein  should  be  seen 
before  any  of  the  deep  glands  are  removed,  for  if  this  structure  is  seen 
it  can  be  carefully  followed  the  whole  length  of  the  neck  without 
wounding  it  nnintentionally.     If  the  internal  jugular  vein  is  imbedded 


TUBERCULOSIS    OF    LYMPH  ATrr    GLAXDS.  479 

among  the  enlarged  glands,  and  cannot  he  isolated  without  great  danger 
of  injuring  it,  it  is  better  to  resect  it  between  two  ligatures  than  to  run 
the  risk  of  wounding  it  accidentally.  The  chain  of  enlarged  glands  is 
followed  as  far  as  possible,  as  it  is  much  better  to  remove  a  few  healthy 
lymphatic  glands  than  to  leave  minute,  almost  invisible  foci  of  the  dis- 
ease. After  all  of  the  infected  glands  have  been  removed  the  continuity 
of  the  divided  muscle  is  restored  by  suturing.  At  least  six  catgut 
sutures  are  necessary  to  join  the  thick  ends  accurately.  I  have  usually 
succeeded  in  removing  all  the  glands  after  division  of  this  muscle  with- 
out dividing  the  spinal  accessory  nerve,  but,  should  this  l)e  necessary, 
the  divided  ends  are  joined  by  suturing  before  the  muscle  is  united. 
Drainage  in  tlie  submaxillary  region  and  at  the  most  dependent  point 
of  the  wound  in  the  neck  must  always  be  established.  The  platysma 
muscle  should  be  united  with  Ijuried  sutures  before  the  skin  is  sutured. 
Wounds  of  the  neck,  on  account  of  the  irregular  outlines  of  the  neck, 
shoulder,  and  chest,  require  a  very  copious  antiseptic  dressing  to  effect- 
ually exclude  the  entrance  of  pathogenic  micro-organisms  after  the 
operation.  The  dressing  should  be  kept  in  place  by  a  few  turns  of  the 
plaster-of-Paris  bandage,  which  also  keeps  the  head  in  proper  position 
during  the  time  required  in  the  healing  of  the  large  wound.  The  sutured 
muscle  must  be  kept  in  a  relaxed  position  until  firm  union  has  taken 
place  between  the  sutured  ends,  which  usually  requires  from  two  to  three 
■weeks.  On  the  second  or  third  day  the  dressing  is  changed,  the  drains 
are  removed,  and,  if  the  wound  has  remained  aseptic,  the  second  dressing 
can  be  allowed  to  remain  for  ten  days  or  two  weeks,  when  it  is  changed, 
and  the  superficial  stitches  are  removed.  If  all  of  the  diseased  tissues 
have  been  removed,  and  the  wound  has  remained  aseptic,  the  healing 
process  will  be  found  nearl}'  completed  at  this  time. 

Local  recurrence  of  the  disease  should  only  stimulate  the  surgeon 
to  continue  the  actiA'e  warfare,  and  glands  are  removed  as  soon  as  they 
can  be  felt.  I  have  repeatedly  performed,  on  the  same  patients,  three  and 
four  oi)erati()ns  in  as  many  years,  and  had  the  satisfaction  of  finally 
eradicating  the  disease  completel}'.  Parenchymatous  injections  of  car- 
bolic acid,  so  strongly  recommended  b}-  Hueter  in  the  treatment  of 
tubercular  glands,  have  little  or  no  effect  in  either  arresting  further 
development  of  the  disease  in  the  affected  glands  or  in  preventing 
further  regional  infection.  I  have  seen,  in  cases  treated  by  this  method, 
glands  finally  destroyed  b}'^  suppuration  caused  by  the  punctures ;  but 
the  bacilli  remained  in  the  cicatricial  tissue,  as  was  evident  b}'  the 
oedematous,  congested  scar,  and  from  here  additional  glands  became 
infected. 

Genzmer   advised    ignipuncture    in    the    treatment   of    tubercular 


4R0  PRINCIPLES   OF   SURGERY. 

glands,  and  claims  for  this  method  excellent  results.  This  treatment  is 
applicable  onl}''  in  cases  where  a  few  of  the  more  superficial  glands  are 
alfected,  and  where  patients  positively  refuse  to  su])mit  to  a  more  radi- 
cal procedure.  It  is  absolutely'  contra-indicated  when  many  glands  are 
affected,  as  in  cases  where  the  glands  are  affected  they  have  undergone 
extensive  secondary  pathological  changes.  The  general  treatment  of 
tuberculosis  of  the  lymphatic  glands  is  the  same  as  in  the  other  forms  of 
local  tuberculosis.  I  have  seen  the  best  effects  from  the  administration  of 
arsenic  and  iron,  followed  or  alternated  by  codliver-oil.  All  external 
applications  to  bring  about  resolution  are  worse  than  useless. 

TUBERCULOSIS    OF    PERITONEUM. 

Tubercular  peritonitis  occurs  as  one  of  the  lesions  of  acute  general 
tuberculosis,  with  chronic  pulmonar}'  phthisis,  with  tubercular  inflamma- 
tion of  the  genito-urinary  tract,  and  as  a  local  inflammation.  As  a  sur- 
gical lesion  only  the  local  form  will  be  considered  here. 

Bacteriological  Remarks. — The  susceptibility  of  the  peritoneum  to 
tubercular  infection  has  been  well  established  by  numerous  inoculation 
experiments.  The  peritoneum  can,  under  favorable  conditions,  dispose 
of  a  large  dose  of  a  pure  culture  of  pus-microbes,  but  the  implantation 
of  a  minute  fragment  of  tubercular  tissue  in  animals  susceptible  to 
tuberculosis  is  almost  certain  to  be  followed  by  genuine  local  and  general 
tuberculosis.  For  the  surgeon,  only  those  forms  of  peritoneal  tubercu- 
losis have  interest  which  are  either  caused  by  an  extension  of  an  adja- 
cent tubercular  process  to  the  peritoneum  or  from  primary  localization 
of  the  bacillus  within  or  upon  this  membrane.  The  prevalence  of  the 
affection  in  the  female  sex  among  the  cases  which  have  been  reported 
})oints  to  the  Fallopian  tubes  as  a  frequent  primary  seat  of  infection, 
with  secondarj'  invasion  of  the  peritoneum  from  this  source.  Although 
the  genital  organs  in  the  male  are  more  frequently  the  seat  of  tubercu- 
losis than  in  the  female,  so  far  only  2  cases  of  peritoneal  tuberculosis  in 
males  have  been  reported, — 1  by  Kiimmel  and  the  other  by  Lindfors. 
Tuberculosis  of  the  peritoneum,  by  extension  from  a  tuberculous  focus 
in  the  genital  organ,  can  only  mean  an  infection  b}'  contact,  the  bacillus 
of  tuberculosis  transferred  from  the  primary  seat  of  infection,  and 
localization  by  implantation  upon  the  peritoneal  surface.  Implantation 
experiments  in  animals  furnish  a  good  illustration  of  the  manner  in 
which  the  process  becomes  diffuse.  At  the  point  of  implantation  a 
granulation  mass  forms  around  the  graft,  and  from  here  innumerable 
tubercle-nodules  take  their  starting-point,  forming  everywhere  new 
centres  of  infection.  The  movements  of  the  abdominal  walls  during 
respiration  and  the  peristaltic  action  of  the  intestines  are  potent  factors 


TUBERCULOSIS   OF    PERITONEUM.  481 

concerned  in  the  local  dissemination  of  the  tubercular  infection.  Ana- 
tomicall}',  the  peritoneum  is  so  closel}'  allied  to  the  13'mphatie  glands 
that  we  have  every  reason  to  believe  that  primary  tuberculosis  can  occur 
in  this  structure  as  well  as  in  the  Ij-mphatic  glands.  In  primary  tuber- 
culosis of  the  peritoneum  infection  takes  place  in  the  same  manner  as  iu 
intact  joints,  by  floating  bacilli  becoming  arrested  in  the  capillary  ves- 
sels of  the  membrane,  where  the  primar}'  nodule  forms,  from  which, 
again,  as  from  a  graft,  local  dissemination  takes  place.  These  cases  are, 
in  the  true  sense  of  the  woi'd,  not  cases  of  primary  tuberculosis,  as  the 
peritoneal  affection  is  only  a  local  expression  of  an  antecedent  infection. 
As  the  peritoneum  is  endowed  with  absorptive  capacities  of  a  high 
degree,  and  is  in  direct  communication  with  the  l3'mphatic  system,  we 
would  naturally  expect  that  tuberculosis  of  this  structure  would  lead  to 
early  general  dissemination.  But  in  peritoneal  tuberculosis  we  observe 
the  same  tendency  to  limitation  of  the  infective  process  as  in  joints,  by 
the  formation  of  an  impenetrable  wall  of  connective  tissue,  whicli 
imparts  so  often  to  this  form  of  peritonitis  its  circumscribed  character. 

Clinical  Studies. — Kiimmel  looks  upon  peritoneal  tuberculosis  as  a 
pureh'  local  affection,  amenable  to  surgical  treatment  in  the  same  sense 
and  to  the  same  extent  as  a  tuberculosis  of  joints.  That  some  of  these 
cases  can  be  permanently  cured  by  local  treatment  is  well  shown  by  a 
case  treated  by  Sir  Spencer  Wells  twentj^-six  years  ago  by  abdominal 
section,  the  patient  having  remained  up  to  this  time  in  perfect  heiilth. 
In  a  recent  paper  on  this  subject  Fehling  reports  4  cases  of  his  own, 
and  gives  an  account  of  all  the  operations  which  had  been  done  up  to 
that  time, — 21  in  number.  Of  this  number  15  recovered,  and  the  patients 
are  known  to  have  been  well  from  one  year  to  twenty-three  years,  and 
in  a  number  of  cases  their  condition  was  learned  four  to  five  years  after 
the  operation.  Six  of  the  patients  died, — 2  of  sepsis,  1  of  p3'temia 
several  months  after  the  operation,  and  3  from  the  continuance  of  the 
disease  for  which  the  operation  was  performed.  In  5  of  the  cases  ascites 
attended  the  tuberculosis  ;  in  3  the  swelling  was  not  due  to  effusion, 
but  to  adhesions  between  intestinal  loops  that  were  covered  with  miliary 
tubercles. 

Of  54  cases  of  laparotomy  for  pei-itoneal  tuberculosis,  collected  by 
Trzebicky,  4  died  from  the  immediate  consequences  of  the  operation, 
while  in  a  fifth  death  occurred  after  the  operation  from  acute  miliary 
tuberculosis,  though  the  fluid  had  not  re-accumulated.  One  case  died  in 
four  months  from  general  tuberculosis  without  the  peritonitis  disappear- 
ing; cures  resulted  in  40  cases,  though  here  and  there  evidence  of  pul- 
monary tuberculosis  was  reported.  The  majority  of  cases  were  females, 
which  may  find  its  explanati(jn  in  the  fact  that  most  were  operated  upon 


482  PRINCIPLES   OF   SURGERY. 

under  error  in  the  diagnosis  of  ovarian  cyst.  The  most  recent  and  com- 
preliensive  work  on  tuberculosis  of  the  peritoneum,  which  has  recentl}^ 
appeared  from  the  pen  of  Vierordt  ("  Ueber  die  Tuberculose  der  serosen 
Haute,"  in  Zeitachrift  f.  klin,  Medicin.^  Bd.  xiii,  Heft  2),  should  be  con- 
sulted by  those  who  wish  to  secure  for  reference  an  exhaustive  treatise 
on  this  subject.  Tlie  statistics  are  3^et  too  meagre,  the  correctness  of 
diagnosis  not  entirely  above  doubt,  and  the  period  of  observation  after 
operation  not  long  enough  ;  but,  in  view  of  the  results,  there  is  no  longer 
any  justification  for  expectant  treatment.  Even  though  in  some  cases 
recovery  was  not  permanent,  the  fluid  did  not  re-accumulate,  and  the 
patients  were  relieved  of  their  disticss.  Spontaneous  recovery  from 
tubercular  peritonitis  is  exceptional,  iuid  operative  interference  is  indi- 
cated the  more,  as  it  would  seem  that,  in  many  cases,  tuberculosis  of  the 
peritoneum  is  a  primar}-  aftection  and  the  source  of  general  infection. 
As  all  other  therapeutic  measures  are  of  no  permanent  value  in  such 
cases,  and  laparotomy  done  under  antiseptic  precautions  may  be  con- 
sidered almost  free  from  danger,  the  operation  is  certainly  stronglj^ 
indicated. 

Pathology  and  Morbid  Anatomy. — The  effect  of  the  bacillus  of  tuber- 
culosis on  the  peritoneum  is  not  uniform,  and  the  conditions  found  in 
peritoneal  tuberculosis  are  variable.  Lindfors,  in  a  clinical  and  patho- 
logical study,  based  on  109  recorded  cases  of  peritoneal  tuberculosis, 
divides  the  cases  into  seven  classes.  He  states  that  the  acute  variety 
may  assume  the  form  of  circumscribed,  general,  or  suppurative  perito- 
nitis ;  in  the  chronic  form  there  may  be  a  free  or  encysted  effusion,  there 
may  be  simple  adhesions,  or  the  intestines  may  be  so  adherent  as  to 
cause  intestinal  obstruction.  Lindfors  thinks  that  the  presence  of  acute 
or  chronic  pleurisv  has  an  important  bearing  on  the  diagnosis  of  tuber- 
cular peritonitis.  He  is  strongly  in  favor  of  laparotomy  and  the  free  use 
of  iodoform  within  the  peritoneal  cavity.  The  conditions  found  in  local 
tubercular  peritonitis,  in  cases  sul)jected  to  operative  treatment  and  in 
examinations  made  in  the  post-mortem  rooms,  are  such  that  all  cases  of 
this  kind  can  be  conveniently  classified  in  three  principal  groups  upon  a 
pathological  basis. 

I.  Tubercular  Ascites. — The  peritoneum  is  thickened,  hypersemic, 
and  studded  with  masses  of  tubercle-tissue  in  the  form  of  miliar}^ 
nodules.  The  omentum  is  usuall}-  similarly  affected.  If  the  effusion  is 
general,  occupying  the  Avhole  peritoneal  cavitj^,  the  adhesions  are  few 
and  slight.  If  the  fluid  is  encapsulated  the  walls  of  the  cavity  are 
formed  by  intestinal  loops,  which  are  adherent  among  themselves  and 
to  the  surrounding  structures.  The  circuniscribed  form  usually  takes 
its  origin  from  the  floor  of  the  pelvis,  and  often  gives  rise  to  a  swelling 


TUBERCULOSIS   OF   PERITONEUM.  -183 

which  simulates  an  ovarian  cj^st  to  perfection.  The  fluid  contained  in 
the  peritoneal  cavitj'  in  the  diffuse  form,  and  in  the  confined  space  in  tlie 
circumscribed  variet}^,  is  either  a  clear,  transparent  serum,  or  serum  in 
■which  small  flocculi  are  suspended,  or  the  fluid  has  become  slightl_y 
turbid  from  the  admixture  of  tlie  products  of  retrograde  tissue  metamor- 
phosis. The  visceral  peritoneum  of  the  organs  exposed  to  infection  is 
in  the  same  condition  as  the  parietal  peritoneum.  Coagulation  necrosis 
and  caseation  of  the  nodules  appear  to  be  retarded  for  a  much  longer 
time  than  in  cases  of  glandular  tuberculosis.  The  amount  of  fluid  may 
vary  from  a  teacupful  in  the  circumscribed  to  4  or  6  gallons  in  diffuse 
tubercular  ascites.  Secondary  infection  is  found  most  frequentl}'  in  the 
spleen,  pleune,  and  13'mphatic  glands. 

2.  Fibrino-plastic  Peritonitis. — In  this  form  of  tubercular  peritonitis 
no  fluid  is  found  in  tlie  peritoneal  cavit}'.  The  bacillus  of  tuberculosis 
produces  a  copious  inflammatory  pi'oduct,  and  the  peritoneal  surfiices, 
which  are  studded  with  miliary  tubercles,  are  covered  b}'  a  thick  layer 
of  gelatinous  fibrin,  which  cements  together  all  the  adjacent  serous 
surfaces,  so  that  tlie  whole  abdominal  cavity  appears  to  be  filled  with  a 
large,  boggy  mass,  composed  of  all  the  viscera  adherent  to  each  other, 
and  with  the  inter-spaces  between  them  filled  with  fil)rin.  The  inflam- 
matorj'  product  in  these  cases  is  rich  in  fibrin-producing  substances, 
while  the  liquid  transudation  is  either  scant}"  or  is  absorbed  as  soon  as 
it  is  poured  out. 

3.  Adhesive  Peritonitis. — In  this  variety  of  tubercular  peritonitis 
the  bacillus  of  tuberculosis  exerts  its  pathogenic  properties  more  on  the 
fixed  tissue-cells  than  the  blood-vessels.  The  primary  inflammatorj- 
exudation  is  slight,  but  the  endothelial  cells  proliferate  new  tissue,  which 
undergoes  cicatrization,  giving  rise  to  firm  and  extensive  adhesions.  The 
plastic  peritonitis  may  be  so  extensive  as  to  cause  intestinal  obstruction 
from  perfect  immobilization  of  a  large  portion  of  the  intestinal  tract. 
In  this,  as  well  as  in  the  foregoing  form  of  tubercular  peritonitis,  ulcera- 
tion of  the  intestine  rna^-  take  place,  resulting  in  the  formation  of  a  bi- 
mucous,  internal  fistula,  if  the  opening  in  two  adjacent  loops  correspond, 
or  the  formation  of  a  faecal  abscess  with  a  subsequent  fjecal  fistula. 

Symptoms  and  Diagnosis. — As  tubercular  peritonitis  without  effusion 
is  not  amenable  to  successful  surgical  treatment  b}^  laparotom}',  nothing 
will  be  mentioned  in  reference  to  the  diagnosis  and  treatment  of  the 
fibrino-plastic  and  adhesive  varieties.  Tubercular  ascites  is  a  chronic 
alTection,  especially  when  it  occurs  in  the  circumscribed  form.  Pain  and 
tenderness  are  not  prominent  or  even  constant  S3'mptoras.  The  general 
health  is  at  first  but  little  impaired.  Fever  is  slight  or  entirely-  absent. 
If  the  effusion  is  general,  it  comes  on  slowlj',  almost  insidiousl}',  as  in 


484  PRINCIPLES    OF    SURGERY. 

ascites  iVoiu  olher  causes.  From  the  aljsence  of  udliesions  the  fluid 
changes  its  location  according  to  the  position  of  the  patient.  If  the 
patient  is  placed  in  the  dorsal,  recumbent  position,  the  lumbar  regions 
are  dull  on  percussion  ;  if  placed  on  the  side,  the  upper  lumbar  region  is 
t3'mpanitic,  while  the  area  of  dullness  on  the  opposite  side  is  increased. 
In  circumscribed  tubercular  peritonitis  with  encapsulation  of  the  fluid, 
the  swelling  appears  first  either  in  the  h^^pogastric  or  one  of  the  iliac 
regions.  The  area  of  dullness  does  not  change  by  placing  the  patient  in 
different  positions.  In  free  ascites  tuberculosis  of  the  peritoneum  should 
be  suspected,  if  the  ordinary  causes  of  ascites,  cirrhosis  of  the  liver, 
valvular  disease  of  the  heart,  and  the  presence  of  an  intra-abdominal 
malignant  tumor  can  be  excluded.  Circumscribed  tubercular  ascites 
might  be  mistaken  for  ovarian  c,yst,  pregnancy,  pyo-  or  hydro-  salpinx, 
and  pelvic  abscess.  Fluctuation  is  a  symi)tom  common  to  all  of  these 
conditions,  and  a  differential  diagnosis  can  onh'  be  made  b}'  a  careful 
stud}'  of  the  clinical  history  and  b}'  a  thorough  examination.  Pregnane}" 
can  usuall}'  be  excluded  by  ascertaining  the  size  of  the  uterus  and  by 
the  presence  or  absence  of  the  usual  signs  of  gestation.  A  P3'0-  or  hj^dro- 
salpinx  can  generally  be  recognized  by  bimanual  exploration,  especially 
if  the  examination  is  made,  as  it  should  be,  under  the  influence  of  an 
anaesthetic.  A  pelvic  abscess  is  always  preceded  by  an  acute  suppura- 
tive para-  or  peri-  metritis,  attended  by  severe  s}'mptoms  which  are  absent 
in  tubercular  peritonitis. 

The  greatest  difficult}'  presents  itself  in  differentiating  between  a 
circumscribed  tubercular  ascites  and  an  ovarian  cyst.  So  close  is  the 
clinical  resemblance  of  these  two  affections  that  a  positive  diagnosis  is 
almost  impossible  without  the  aid  of  an  exploratory  laparotomy,  and,  as 
both  affections  can  only  be  treated  successfully  by  abdominal  section,  it  is 
sufficient  for  all  practical  purposes  to  narrow  the  diagnosis  down  to  one 
of  these,  and  reserve  a  positive  diagnosis  until  the  abdomen  is  opened. 

Treatment. — The  surgical  treatment  of  tubercular  peritonitis  with 
effusion  by  laparotomy  has  yielded  sufficiently  satisfactory  results  to 
make  it  an  established  procedure  in  such  cases  in  the  future.  A  spon- 
taneous cure  is  the  exception  ;  death  from  local  extension  of  the  disease 
and  from  general  infection  the  rule.  A  case  came  under  my  observation 
during  the  last  two  years  where  I  have  every  reason  to  believe  that 
tubercular  ascites  disappeared  spontaneously.  The  patient  was  a  woman, 
40  years  of  age,  with  a  marked  hereditary  tendency  to  tuberculosis,  sev- 
eral sisters  having  died  of  pulmonary  tuberculosis.  She  is  the  mother 
of  several  children,  the  youngest  being  6  years  old.  Two  years  ago  she 
was  brought  to  me  by  her  family  physician  with  the  diagnosis  of  ovarian 
cyst.    At  that  time  the  swelling  was  as  large  as  a  child's  head,  occupying 


TUBERCULOSIS   OF   PERITONEUM.  485 

the  lij'pogastric  and  left  iliac  region.  Fluctuation  distinct ;  no  pain 
and  but  little  tenderness  on  pressure  ;  menstruation  regular.  General 
health  only  slightlj'  impaired.  After  a  careful  examination  I  coincided 
with  the  diagnosis,  and  advised  an  earl}-  operation.  Soon  after  this  time 
the  swelling  began  to  diminish  in  size  and  disappeared  completely  in  the 
course  of  a  3'ear,  but  the  general  health,  instead  of  improving,  began  to  fail. 
After  the  disappearance  of  the  swelling  she  began  to  suffer  from  a  deep- 
seated  pain  at  a  point  corresponding  to  the  cartilage  of  the  eighth  rib  on 
the  left  side,  and  in  the  course  of  a  few  months  a  fluctuating  swelling 
appeared  under  the  costal  arch  at  that  point.  Tuberculosis  of  the  ribs 
was  suspected,  but  at  the  time  of  operation  an  encapsulated  tubercular 
abscess  was  found  in  the  abdominal  cavit3',to  the  left  of  the  great  curva- 
ture of  the  stomach  arid  above  the  splenic  flexure  of  the  colon.  A  large 
quantity  of  liquefied,  caseous  material  was  evacuated.  The  wall  of  the 
abscess  was  lined  with  a  thick  layer  of  granulation  tissue,  which  was 
thoroughl}'  removed  with  a  sharp  spoon,  and  after  irrigation  the  cavity 
was  carefully  dried  and  packed  with  iodoform  gauze.  The  wound 
healed  b}-  primar}-  intention,  and  the  entire  cavity  closed  in  the  course 
of  four  weeks  witiiout  a  drop  of  pus.  The  woman  has  since  greatl}-  im- 
proved in  health,  and  is  completely  relieved  of  her  pain.  There  can 
hardly  be  a  question  that  the  accumulation  of  fluid  which  was  mistaken 
for  an  ovarian  cyst  was  a  limited  ascites,  caused  hy  a  circumscribed 
tubercular  peritonitis,  and  that  the  infection  in  the  upper  portion  of  the 
abdominal  cavit}'  resulted  from  this,  tlie  primary  depot.  It  is  not  at  all 
improbable  that,  had  an  operation  been  performed  at  the  time  it  was  ad- 
A'ised,  this  extension  of  the  infection  might  have  been  prevented.  The 
results  obtainable  b}^  laparotoni}'  in  the  two  different  forms  of  tubercular 
ascites  are  well  shown  b3'  2  cases  which  occurred  in  my  practice  during 
the  last  year. 

The  first  patient  v/as  a  girl,  1*7  years  old,  without  a  tubercular  his- 
tory. She  had  alwa^'s  been  in  good  health  until  about  a  j'ear  ago,  when 
she  commenced  to  suffer  from  pain  in  the  left  iliac  region,  and  soon  after 
a  perceptible  swelling  appeared  in  that  localit}',  which  graduall}'  in- 
creased in  size  until  the  time  I  saw  her,  when  it  reached  above  the  um- 
bilicus and  beyond  the  median  line.  Has  never  menstruated.  Patient  is 
anfsemic  and  somewhat  emaciated,  but  was  never  confined  to  bed.  Ex- 
amination reveals  no  disease  in  any  of  the  important  organs.  Diagnosis 
of  ovarian  cyst  had  been  made  by  several  ph3sicians.  The  abdomen 
was  opened  b}'  a  median  incision,  and  a  large  quantity  of  clear,  straw- 
culored  serum  escaped  as  soon  as  the  peritoneum  was  incised.  The  parietal 
peritoneum,  as  well  as  the  intestines,  which  formed  a  part  of  the  wall  of 
the  cavity,  were  studded  with  innumerable  nodules  the  size  of  millet-seed. 


486  PRINCIPLES   OF    SURGERY. 

These  nodules  were  largest  and  most  numerous  in  the  region  of  the 
left  Fallopian  tube,  which,  however,  was  normal  in  size.  The  cavity 
was  dried  and  freel}^  dusted  with  iodoform,  and  a  Keith  glass  drain 
inserted  as  far  as  the  floor  of  the  space  of  Douglas.  A  large  quantity 
of  serum  was  removed  from  the  tube  for  the  first  few  da^'s,  when  it 
became  more  and  more  scant}',  so  that  the  glass  tube  could  be  removed 
at  the  end  of  the  second  week.  Through  a  small  fistulous  tract  serum 
continued  to  escape  for  six  weeks,  when  the  fistula  closed.  The  patient 
has  gained  15  pounds  in  weight,  and  at  this  time,  a  ^'ear  after  the  opera- 
tion, is  in  perfect  health,  with  no  signs  of  a  local  return.  That  the  peri- 
tonitis in  tliis  case  was  tubercular  was  demonstrated  by  an  inoculation 
experiment.  A  nodule  was  removed  from  the  peritoneum  and  implanted 
into  the  peritoneal  cavity  of  a  guinea-pig  with  a  positive  result.  The 
second  case  was  a  woman,  42  3-ears  of  age,  without  any  history  of  tuber- 
culosis in  her  family.  She  is  the  mother  of  a  large  familj-,  the  youngest 
child  being  5  years  of  age.  Her  abdomen  began  to  enlarge  four 
months  before  she  came  under  m}'  care.  Pain  not  severe,  but  gradual 
loss  of  flesh  and  strength.  As  no  local  cause  for  the  ascites  could  be 
found,  the  abdomen  was  opened  in  the  median  line,  and  at  least  two  pail- 
fulls  of  clear  serum  escaped.  The  intestines  and  parietal  peritoneum 
presented  an  exceedingly  vascular  appearance,  and  were  studded  with 
minute  miliar}'  nodules.  These  nodules,  again,  were  largest  in  the  pelvis, 
but  both  tubes  were  found  in  a  normal  condition.  The  same  course  was 
pursued  as  in  the  first  case,  and  drainage  was  kept  up  for  two  weeks, 
when  the  flow  of  serum  was  so  scant}'  that  it  was  deemed  advisable  to 
remove  the  tube.  The  wound  healed  completel}'  in  a  few  days,  and  the 
patient  left  the  hospital  greath'  relieved.  The  fluid,  however,  accumu- 
lated so  rapidly  that  in  two  weeks  she  had  to  be  tapped,  and  from  this 
time  on  the  patient  could  not  leave  her  bed.  The  tapping  had  to  be  re- 
peated ever}'  two  weeks.  Symptoms  of  pulmonary  phthisis  developed 
soon  after  she  left  the  hospital,  and  death  from  general  miliary  tubercu- 
losis occurred  in  less  than  three  months  after  the  operation.  The 
danger  of  re-accumulation  of  fluid  and  general  infection  is  much  greater 
in  diffuse  tubercular  peritonitis  than  in  the  circumscribed  form,  as  in  the 
latter  the  are;i,  of  infection  is  more  limited,  and  general  infection  is  less 
likely  to  occur  on  account  of  the  presence  of  a  wall  of  plastic  material 
which  surrounds  the  tubercular  field.  In  operating  for  circumscribed 
tubercular  ascites  it  is  very  important  to  exercise  great  care  in  opening 
the  abdominal  cavity,  as  a  loop  of  adherent  intestine  may  be  found  at  the 
point  where  the  incision  is  made.  The  peritoneum  must  be  recognized 
and  carefully  divided  in  order  to  prevent  wounding  of  the  bowel,  should 
such  a  condition  be  met  with.     lodoformization  of  the  cavity  is  one  of  the 


TUBERCULOSIS   OF    PERITONEUM.  487 

important  indications  of  treatment.  Drainage  must  be  maintained  until 
accumulation  of  serum  in  the  tube  has  ceased.  Uniform  equable  com- 
pression of  the  abdomen  with  strips  of  adhesive  plaster  or  a  well-fitting 
bandage  should  be  kept  up  throughout  the  entire  after-treatment.  In 
cases  where  a  well-defined  local  tubercular  focus  is  found,  which  we  have 
reason  to  regard  as  the  cause  of  the  peritonitis,  this  should  be  removed 
or  rendered  harmless  by  appropriate  treatment.  A  tubercular  Fallopian 
tube  should  be  removed  if  this  can  be  done.  Other  caseous  foci  are  re- 
moved with  a  sharp  spoon,  or  the}'  can  be  destroyed  or  rendered  harmless 
by  igniquncture  and  thorough  iodoformization. 


CHAPTER  XX. 

Tuberculosis  of  Bones  and  Joints, 
tuberculosis  of  bone. 

Next  to  tlie  lungs  and  Ij'nipbatic  glands  the  bones  are  most  fre- 
quentl}'  the  seat  of  tubercular  infection.  Tuberculosis  of  the  bones  is 
an  exceedingly  frequent  affection  in  children  and  3'oung  adults.  Its 
favorite  location  is  in  the  epiphyseal  extremities  of  the  long  bones, 
although  it  is  also  quite  frequently  met  with  in  the  short  bones  of  the 
carpus  and  tarsus  and  some  of  the  flat  and  irregular  bones,  as  the  ribs, 
scapula,  ileum,  and  vertebrae. 

Embolic  Infection  the  Cause  of  Osseous  Tuberculosis. — Practically, 
direct  tubercular  infection  does  not  occur,  and  when  the  disease  has 
made  its  appearance  it  is  onl}'  an  evidence  of  the  existence  of  a  tuber- 
cular focus  in  some  other  organ.  We  observe  clinically,  what  Mueller 
has  demonstrated  experimentally',  that,  when  the  bacilli  of  tuberculosis 
are  present  in  the  blood-current,  verj'  often  localization  t.akes  place  near 
the  epiphyseal  cartilage  in  young  persons  Iw  the  microbes  becoming 
arrested  in  one  of  the  terminal  branches  of  an  artery,  the  lumen  of 
which  becomes  obliterated  by  tlie  presence  of  a  minute  embolus  of 
granulation  tissue  containing  bacilli;  or  the  lumen  of  the  vessel  is 
gradualh'  diminished  by  the  formation  of  a  mural  thrombus,  which 
forms  around  bacilli  implanted  upon  the  vessel-wall,  and  the  lumen 
of  the  vessel  is  finally  completel}'^  obstructed  by  the  growth  of  the 
thrombus. 

The  new  vessels  in  the  vicinity  of  the  centres  of  growth  in  the  bones 
of  voung  persons,  on  account  of  their  imperfect  structure  and  irregular 
contour,  furnish  the  most  fiiA'orable  conditions  for  the  arrest  of  floating 
granular  matter  and  the  localization  of  pathogenic  microbes.  The  pre- 
disposing anatomical  element  goes  far  to  explain  the  frequency  with 
which  we  meet  with  tubercular  foci  in  the  epiphyseal  extremities  of  the 
long  bones. 

The  following  table,  prepared  by  Schmallfuss,  gives  a  good  idea 
of  the  relative  frequency  with  which  different  bones  are  affected  with 
tubercular  lesions : — 

(489) 


490 


PRINCIPLES   OF    SUKGERY. 


Billroth. 

Jaffe. 

Feb  Cent. 

SCHMALLFUSS. 

Per  Cent. 

Vertebra. 

Vertebra. 

26 

Knee. 

23 

Knee. 

Foot. 

21 

Foot. 

19 

Cranium  and  Face. 

Hip. 

13 

Hip. 

16 

Hip. 

Knee. 

10 

Elbow. 

9 

Sternum  and  ribs. 

Hand. 

9 

Hand. 

8 

Foot. 

Elbow. 

4 

Vertebra. 

7.5 

Elbow. 

Pelvis. 

3 

Tibia. 

4 

Pelvis. 

Cranium. 

3 

Cranium. 

4 

Tibia,  Fibula,  and 

Sternum,  Clavicle, 

Pelvis. 

3.6 

Femur. 

and  Ribs. 

3 

Sternum,  etc. 

3.6 

Shoulder. 

Shoulder. 

2 

Femur. 

1.9 

Femur. 

1 

Shoulder. 

1.5 

Humerus. 

Tibia. 

1 

Ulna. 

1.4 

Ulna. 

Fibula. 

1 

Humerus. 

1 

Radius. 

Humerus. 

1 

Radius. 

0.7 

Scapula. 

Scapula. 

0.6 

Fibula. 

0.5 

Ulna. 

0.6 

Patella. 

0.1 

It  is  safe  to  state  that  before  puberty  the  primary  lesion  in  tuber- 
cular affections  of  joints  is  located  in  one  or  both  of  the  epiphyses  of 
the  bones  which  enter  into  the  formation  of  the  joint,  while  in  the  adult 
primary  tuberculosis  of  the  synovial  membrane  is  of  more  frequent 
occurrence.  As  age  advances  and  the  process  of  ossification  is  com- 
pleted, the  predisposing  localizing  causes  in  bone  apparently  disappear, 
while  the  s^-novial  membrane  becomes  more  susceptible  to  primary 
localization.  Of  204  specimens  of  tubercular  joints  obtained  from 
patients  of  all  ages,  examined  by  Mueller,  158  were  primary  osteal,  and 
46  primary  sj-novial,  tuberculosis. 

Artificial  Tuberculosis  of  Bone  Produced  by  Direct  Intra-vascular 
Infection. — Wm.  Mueller,  formerly  one  of  Konig's  assistants,  produced 
the  characteristic  clinical  form  of  tuberculosis  in  bone  experimentally 
b}'  injecting  tuberculous  material  into  the  nutrient  arter}'  of  long  bones. 
Konig  for  a  long  time  had  claimed  that  the  wedge-shaped  sequestrum, 
so  constantly  found  in  tubercular  foci  in  the  articular  extremities  of  the 
long  bones  was  due  to  occlusion  of  a  small  artery  by  a  tubercular 
embolus.  Mueller's  experiments  were  undertaken  to  produce  this  con- 
dition artificially.  He  made  16  experiments  on  rabbits,  injecting  tuber- 
culous pus  into  the  femoral  arter}^,  some  in  a  peripheral,  some  in  a 
central  direction,  without  any  positive  results  following.  In  a  second 
series  the  same  material  w^as  thrown  directly  into  the  nutrient  arteries 
of  the  femur  and  tibia.  Of  10  of  these  cases  2  showed  a  tuberculous 
focus  in  the  medulla  of  the  diaphysis  of  the  tibia ;  in  another  case 
miliary  tuberculosis  in  the  femur  and  tibia,  and  in  the  latter  bone  a 
small  caseous  nodule  in  the  spongy  part  which  contained  numerous 
bacilli.     The  animals  were  killed  eight  weeks  after  injection,  and  showed 


TUBERCULOSIS    OF   BONE.  491 

no  evidences  of  organic  disease  except  a  few  tubercles  in  the  lungs. 
Twent}'  experiments  were  made  on  young  goats,  5  on  sheep,  and  2 
on  dogs.  The  tuberculous  material  was  injected  directly  into  the 
nutrient  arter}'  of  the  tibia,  the  tibial  artery  being  tied  above  and  below 
the  junction  with  this  vessel.  Primary  union  of  the  wound  was  obtained 
in  all  cases  except  in  one  dog.  In  the  dogs  and  sheep  all  experiments 
resulted  negativel}'.  In  the  goats  bone  affections  were  produced  that 
were  identical  with  tubercular  bone-lesions  found  in  man.  Most  fre- 
quently the  disease  was  established  in  the  diaphysis,  cheesy  masses  and 
granulation  tissue  showing  themselves  in  the  medulla  and  cortical 
portion  of  the  bone,  or  tuberculous  osteomyelitis  with  or  without 
sequestration.  T3q)ical  lesions  were  also  found  in  the  ends  of  the  bones, 
with  and  without  implication  of  the  adjacent  joints.  In  2  of  these  cases 
the  epiphysis  was  affected,  while  in  3  the  shaft  was  involved.  The 
following  experiment  made  by  him  furnishes  a  good  illustration  of  the 
identity'  of  the  bone  disease  produced  experimentally  with  the  disease 
as  it  occurs  in  man. 

Tuberculous  material  was  injected  into  the  tibial  artery  of  a  goat  3 
months  old.  Wound  healed  in  eight  days.  Some  lameness  four  months 
later,  gradually  increasing  during  the  next  nine  months.  At  the  same 
time  a  swelling  appeared  at  the  knee-joint.  Tibia  painful  on  outer  side. 
Animal  killed  thirteen  months  after  the  injection.  At  the  necropsy 
there  was  found  a  t^'pical  fungous  disease  in  the  knee-joint,  most  ad- 
vanced at  the  lateral  aspects  of  the  joint ;  a  wedge-sha[>ed  sequestrum 
in  one  of  the  tuberosities  of  the  tibia,  a  small  granulation  mass  in  the 
centre  of  the  head  of  the  tibia,  and  two  similar  granulation  masses  in 
the  lower  ei)iphysis  of  the  femur.  Excepting  the  13'mphatic  glands  of 
the  knee-joint,  no  other  organs  were  aft'ected.  In  some  of  the  cases, 
pulmonary  tuberculosis,  twice  general  miliary  tuberculosis.  The  re- 
mainder of  the  animals  were  killed  when  the^-  began  to  show  lameness — 
fourteen  days  to  thirteen  months  after  infection.  The  tubercular  lesions 
thus  produced  were  examined  for  bacilli,  and  these  were  never  found 
absent.  The  starting-point,  in  every  instance,  must  have  been  a  tuber- 
cular embolus  in  one  of  the  ultimate  minute  branches  of  the  nutrient 
arter}-  near  the  ei)iphyseal  extremity  of  the  bone. 

Clinical  and  Bacteriological  Researches. — Schuchardt  and  Krause 
examined  a  great  variety  of  tubercular  lesions,  and  came  to  the  conclu- 
sion that  tubercle  Inicilli  can  be  found  in  them  without  exception,  but, 
as  a  rule,  few  in  iium])er,  and  often  only  to  be  detected  after  long  and 
patient  search.  'iMiey  found  them  invariably  present  in  cases  of  second- 
ary and  priniaiy  tuberculosis  of  sj'novial  membranes,  tuberculosis  of 
bone,  in  tubercular  abscesses,  and   in   the  latter  cases   not  in   the  fluid 


492  PRINCIPLES   OF    SURGERY. 

contents,  but  in  the  granulations  lining  the  abscess-wall.  Renken  found 
the  bacillus  of  tuberculosis  in  all  cases  of  spina  ventosa  ■which  lie  exam- 
ined. Mueller  carefull}-  studied  numerous  specimens  of  synovial  and 
bone  tuberculosis,  with  special  reference  to  the  existence  of  the  bacillus 
of  tuberculosis,  and,  although  the  results  in  a  number  of  cases  were 
negative,  he  believes  that  the  most  intimate  and  direct  etiological 
relations  exist  between  the  bacillus  and  all  tubercular  lesions  in  bones 
and  joints.  Among  others  who  have  shown  the  never-failing  presence 
of  the  bacillus  in  dilferent  forms  of  surgical  tuberculosis,  including 
bones  and  joints,  may  be  mentioned  Kanzler,  Mogling,  Bouilly,  and 
Letulle.  Tub(!rculosis  of  bone  and  fungous  disease  of  joints,  like  lym- 
phatic tuberculosis,  have  been,  and  by  some  are  still,  regarded  as  scrofu- 
lous affections.  Kanzler  wished  to  make  a  distinction  between  scrofula 
and  tuberculosis,  as  he  found  the  bacilli  not  as  constant  in  the  former, 
and  observed  that,  after  implantation  of  tissue  of  wdiat  he  regarded  as 
scrofulous  affections  in  animals,  the  process  was  slower  than  after  inocu- 
lation with  the  products  of  recognized  forms  of  tuberculosis.  Letulle 
considers  scrofula  and  tuberculosis  as  belonging  to  one  and  the  same 
disease,  of  which  the  former  constitutes  the  milder  form,  and  appearing 
externall}'',  while  the  latter  represents  the  graver  form,  attacking  by 
preference  the  internal  organs.  The  points  made  by  the  last  two  authors 
are  too  unimportant  for  further  consideration  as  a  scientific,  or  even 
practical,  distinction  between  scrofula  and  tuberculosis  as  applied  to 
affections  of  tlife  bones  or  any  other  organs.  The  surgeon  must  recognize 
every  lesion  as  tubercular  in  its  origin,  nature,  and  course  in  which  the 
bacillus  of  tuberculosis  can  be  found,  from  which  successful  cultivations 
can  be  made ,  and  with  ivhich  the  disease  can  be  artificially  i^t'oduced  in 
animals  by  inoculation.  The  presence  of  the  bacillus  of  tuberculosis  in 
the  bod}'  and  its  localization  in  the  medullary  tissue  of  bone  is  the  con- 
ditio sine  qua  non  in  the  causation  of  osseous  tuberculosis.  The  influence 
of  traumatism  in  the  etiology  of  tuberculosis  of  the  bones  and  joints 
has  been  greatly  overestimated.  Traumatism  as  an  etiological  factor 
occupies  a  subordinate  role,  inasmuch  as  it  only  proves,  at  least,  as  an 
exciting  cause  in  persons  already  infected  with  the  essential  cause.  Max 
Schiiller  proved  experimentally  in  animals  infected  with  tuberculosis 
(for  instance,  through  the  respiratory^  tract)  that  a  slight  traumatism 
to  a  joint  wOuld  determine  localization  of  the  microbes  floating  in  the 
blood-current  in  the  part  injured,  and  that  a  tubercular  synovitis  or 
pararthritis  would  follow. 

Clinically,  tuberculosis  of  the  bones  can  be  traced  only  in  a  small 
per  cent,  of  the  cases  to  a  traumatic  origin.  It  is,  as  Volkmann  asserted 
long  ago,  characteristic  that  the  traumatism  is  always  slight,  often  quite 


TUBERCULOSIS    OF    BONE.  493 

insignificant ;  tuberculosis  of  bone,  even  in  tubercular  subjects,  seldom, 
if  ever,  follows  a  fracture,  as  the  injur}^  in  such  cases  is  productive  of 
such  active  cell  proliferation  that  will  neutralize  the  pathogenic  action 
of  the  bacilli,  which  might  reach  the  seat  of  injury  with  the  extra vasated 
l)lood.  It  is  also  possible  that  in  many  eases,  at  least,  the  attention  of 
the  patient  or  his  friends  is  first  accidentallj'  called  to  an  existing  tuber- 
cular focus  b}'  the  immediate  effects  of  the  injury,  the  latter  having  had 
no  influence  in  the  causation  of  the  disease.  Ever}' child  Inrge  enough 
to  run  around  injures  himself  more  or  less  (almost)  dail}',  and  yet  tuber- 
culosis of  the  bones  and  joints  follows  as  a  consequence  onh'  in  compar- 
atively few,  and  in  such  cases  the  essential  cause  must  be  present  in  the 
blood  or  tissues  at  the  time  the  injury  is  received.  As  has  been  previ- 
ously stated,  what  is  generally  regarded  as  local  bone  tuberculosis  (by 
which  we  mean  the  absence  of  recognizable  tubercular  lesions  in  other 
organs)  is  in  renlity  a  secondary  disease,  resulting  from  the  introduction 
of  bacilli  through  the  respiratory  or  alimentarj^  tract  into  the  circulat- 
ing blood,  with  localization  in  the  bone,  or  the  entrance  of  bacilli  into 
the  circulation  from  a  pre-existing  but  undetectable  tubercular  product 
with  secondary''  localization  in  bone.  In  this  sense  a  primary,  or,  to  use 
a  more  correct  expression,  a  localized  osseous  or  articular  tuberculosis 
is,  according  to  Kummer,  found  in  about  40  per  cent,  of  the  cases  ;  in 
the  remaining  60  per  cent,  depots  are  found  at  the  same  time  in  other 
organs  of  the  bod}^ ;  the  lung  comes  first,  with  25  per  cent. ;  other  joints, 
10  per  cent. ;  other  bones,  10  per  cent. ;  13'mphatic  glands,  10  per  cent.; 
peritoneum.  .3  per  cent.  :  pleura,  2  i)er  cent. 

Pathology  and  Morbid  Anatomy. — The  tubercle  bacillus  has  a  distinct 
predisposition  for  the  medullar}^  tissue  of  the  bones,  and  especially  for 
the  red  medullary  tissue  in  the  cancellated  tissue  in  the  region  of  the 
epiphyseal  cartilage  of  the  long  bones.  As  an  inflammatory  affection  it 
is  more  correct  to  speak  of  tuberculous  osteomyelitis  than  tuberculosis 
of  bone,  since  the  medullary  tissue  and  the  blood-vessels  which  it  con- 
tains are  the  parts  that  take  an  active  part  in  the  inflammatorj-  process. 
The  anatomical  conditions  of  the  vessels  in  the  epiphj^seal  pegion  of  the 
long  bones  in  3'oung  persons,  and  in  the  vessels  of  the  medullar}^  tissue, 
favor  implantation  of  the  microbes  upon  the  vessel-wall,  and  the}'  also 
explain  the  frequenc}'  with  which  localization  of  the  tubercular  process 
takes  place  in  this  locality.  The  shaft  of  the  long  bones  is  generally 
exempt  from  tubercular  disease,  with  the  exception  of  the  phalanges  of 
the  fingers  and  toes,  and  the  metacarpal  and  metatarsal  bones  in  chil- 
dren, where  the  tuberculous  osteomyelitis  gives  rise  to  the  well-known 
spina  ventosa  of  the  old  authors.  As  soon  as  embolic  infection  in  bone 
has  taken   place,  a  process  of  osteoporosis  and  decalcification   occurs 


494  PRINCIPLES    OF    SURGERY. 

around  the  tubercular  embolus  or  thrombus,  and  the  preexisting  medul- 
lar\'  and  connective  tissues  are  transformed  into  embryonal  or  granula- 
tion cells,  which  imparts  to  the  product  of  the  specific  inflammation  its 
characteristic  fungous  appearance.  It  is  not  often  that  onl}-  a  single 
focus  of  tubercular  infection  in  bone  is  present;  more  frequently  two  or 
three  foci  appear  in  the  same  region  simultaneously  or  in  slow  or 
rapid  succession,  and  it  is  not  unusual  to  find  that  two  neighboring 
epiphyses  are  infected  at  the  same  time  or  during  the  course  of  the  dis- 
ease. In  bone  the  granulation  tis-ue  undergoes  the  same  series  of  sec- 
ondary degenerative  tissue  changes  as  in  the  lymphatic  glands  ;  hence, 
in  advanced  cases  we  expect  to  meet  with  caseation,  liquefaction  of  the 
cheesy  material,  and  suppuration  in  cases  of  secondary  infection  with 
P3'0genic  microbes.  The  obstruction  of  a  small  arter\-  b}-  an  embolus  or 
thrombus  which  contains  tubercle  bacilli  usually  leads  to  necrosis  and 
sequestration  of  a  triangular  piece  of  bone,  which,  in  its  outlines,  marks 
the  area  of  tissue  which  received  its  blood-suppl}-  from  the  obstructed 
vessel ;  thus  the  triangular  sequestra  are  formed  that  are  so  frequently 
met  with  in  osteal  tuberculosis  of  the  epiphyseal  extremities.  If  the 
embolus  is  located  on  the  side  of  the  epiphyseal  cartilage  toward  the 
joint,  the  base  of  the  triangular  sequestrum  is  directed  toward  tlie  joint, 
and  not  infrequenth'  projects  slight!}'  into  the  joint.  It  is  seldom  that 
tuberculosis  of  bone  develops  in  the  course  of  pulmonary  tuberculosis, 
but  pulmonary  and  diffuse  miliary  tuberculosis  can  be  traced  frequently 
to  a  tuberculous  osseous  focus.  The  intimate  relations  which  exist 
between  the  tubercular  nodule  in  bone  and  the  blood-vessels  furnish  a 
satisfactorj*  explanation  of  the  frequency  with  which  s^'stemic  infection 
takes  place.  A  person  once  infected  with  the  bacillus  tuberculosis  is 
liable  to  suffer  from  the  different  forms  of  localized  tuberculosis,  and 
finalh' dies  of  pulmonary  or  general  miliar}'  tuberculosis.  Yolkmann  has 
well  said  that  a  child  suffering  from  glandular  tuberculosis  has  a  good 
chance  to  become  the  subject  of  osseous  tuberculosis  during  adolescence, 
and  to  die  of  pulmonar}-  tuberculosis  before  reaching  the  age  of  30.  As 
soon  as  the  granulation  process  in  bone  reaches  an  adjacent  vein,  the 
tissues  constituting  the  vein-wall  undergo  the  same  process,  the  bacilli 
reach  the  lumen  of  the  vessel  and  re-enter  the  S3'3temic  circulation,  and 
give  rise  to  miliary  tuberculosis  in  organs  which  are  anatomically  pre- 
disposed to  secondary  infection.  As  long  as  decalcification  of  the  sur- 
rounding bone  goes  on  the  infection  is  progressive,  but  as  soon  as 
osteosclerosis  takes  its  place  the  process  becomes  limited  ;  the  micro- 
organisms are  shut  in,  as  it  were,  by  an  impermeable  wall  of  sclerosed 
bone.  Tlie  most  unfavorable  conditions  are  created  in  cases  in  which 
the   tubercular  focus  becomes  the  seat  of  a  secondarj*  infection  with 


TUBERCULOSIS    OF    BONE.  495 

pyogenic  microbes,  as  tlie  suppurative  process  opens  up  to  the  bacillus 
of  tuberculosis  new  areas  for  invasion,  in  which  the  resistance  of  the 
tissues  to  tubercular  infection  has  already  been  greatly  diminished.  It 
is  also  during  the  suppurative  stage  that  joint  complications  are  most 
likel}'  to  arise.  The  clinical  history  of  cases  of  tuberculosis  of  bone,  as 
well  as  the  macroscopical  and  microscopical  appearances  of  the  lesion, 
are  typical  of  tuberculosis  as  found  in  other  organs.  The  crucial  test 
which  proves  the  tubercular  character  of  most  of  the  chronic  inflamma- 
tory aftections  of  bone  in  children  has  been  furnished  by  bacteriological 
investigations  and  experimental  research.  Most  of  the  investigators  who 
have  studied  this  subject  agree  that  in  tubercular  bone  affections  it  is 
sometimes  very  difficult  to  find  the  bacillus,  that  it  is  not  found  in  great 
abundance,  and  that  sometimes  it  has  evaded  even  the  most  careful 
search.  According  to  Konig,  who  is  authorit}'  on  everything  that  per- 
tains to  tuberculosis  of  bones  and  joints,  all  cases  of  osteo-tuberculosis 
can  be  arranged  under  four  principal  groups,  according  to  the  predomi- 
nating pathological  conditions  of  the  lesions  :  1.  The  granulating  focus. 
2.  The  tubercular  necrosis.  3.  The  tuberculous  infarct.  4.  Diffuse 
tuberculous  osteomyelitis. 

1.  The  granulating  focus  is  found  as  single  or  multiple,  round  or 
oval  cavities,  from  the  size  of  a  millet-seed  to  that  of  a  pea  or  hazel-nut, 
containing  living  embryonal  tissue,  or,  if  this  has  been  destro^yed  by 
coagulation  necrosis  and  caseation,  a  yellowish-gra}',  cheesy  material,  or 
liquid  tuberculous  pus.  Minute  spiculse  of  bone  are  imbedded  among 
the  granulations  or  suspended  in  the  liquefied  caseous  material.  Histo- 
logically, the  granulation  material  is  composed  of  the  same  cell-elements 
as  recent  tubercle  in  other  organs,  only  that,  as  a  rule,  the  giant  cells  are 
more  numerous  and  of  larger  size.  If  caseation  has  taken  place,  the 
chees}'  material  is  surrounded  b}'  a  zone  of  granulation  tissue.  As  long 
as  the  process  has  not  come  to  a  stand-still,  the  surrounding  bone  is 
osteoporotic,  and  can  be  easilj'  scraped  out  with  a  sharp  spoon.  As  soon 
as  the  inflammator}^  process  has  subsided  the  osteoporotic  bone  becomes 
sclerosed,  and  the  tubercular  focus  is  walled  in  and,  for  the  time  being, 
is  rendered  harmless.  Cheesy  tubercular  cavities  in  bone  resemble  the 
same  condition  in  the  lungs,  onl}^  that  secondary'  infection  with  pus- 
microbes  is  of  less  frequent  occurrence,  and  on  this  account  the  cavity 
never  attains  such  large  size  as  in  the  latter  organ. 

2.  Tubercular  necrosis  necessaril}^  follows  if  the  infected  area  exceed 
the  size  of  a  hazel-nut.  The  non-vascular  structure  of  the  tubercular 
product  and  the  blocking  and  destruction  of  blood-vessels  during  the 
earl}'  stages  of  the  tubercular  inflammation  produce  early  death  of  the 
bone,  corresponding  to  the  limits  of  the  inflammation,  and  if  this  exceed 


496  PRINCIPLES   OF    SURGERY. 

the  resorption  capacity  of  tlie  granulation  tissue  the  dead  tissue  is  not 
removed  by  absorption,  and  is  found  as  a  sequestrum  as  soon  as  it  has 
become  detached  from  the  surrounding  healthy  bone.  If  the  tubercular 
process  has  been  rapid  and  the  granulation  tissue  is  scant3',tlie  necrosed 
bone  is  not  osteoporotic;  but  if  the  disease  has  pursued  a  more  clironic 
course,  and  has  resulted  in  the  production  of  an  abundance  of  granula- 
tion tissue,  it  presents  a  honey -combed  appearance,  is  irregular  in  shape 
and  in  size,  does  not  correspond  with  the  area  of  the  infected  district,  as 
part  of  it  has  been  absorbed  by  the  granulations.  Its  color  depends  on 
the  condition  of  the  granulations  which  surround  it;  if  these  have  not 
undergone  secondary  degenerative  changes  it  may  resem])le  health}' 
bone,  but  if  caseation  has  taken  place  it  is  infiltrated  witli  the  cliees}^ 
material,  and  then  presents  a  grayish-yellow  or  yellow  appearance.  If 
tlie  necrosed  bone  has  undergone  no  reduction  in  size,  and  the  granula- 
tions surrounding  it  are  few,  it  remains  firmly  wedged  in  position, 
and  under  such  circumstances  it  is  often  difficult  to  locate  the  exact 
boundary-line  between  it  and  the  surrounding  healthy  bone  or  to  dis- 
lodge it  from  its  position. 

3.  The  tuberculous  infarct  is  only  another  form  of  tubercular 
necrosis,  and  is  separately  classified  because  llie  necrosed  bone  is  always 
wedge-shaped,  and  the  necrosis  has  been  caused  b^^  the  impaction  of  an 
embolus  containing  tubercle  bacilli  in  a  distal  branch  of  a  nutrient 
artery.  The  size  of  the  vessel  obstructed  by  an  infected  embolus  will 
determine  the  extent  of  the  necrosis.  If  the  embolus  is  small,  the  area 
of  necrosis  may  be  increased  by  the  blocked  vessel  becoming  the  seat  of 
secondary  thrombosis,  obliteration  of  the  vessel  taking  place  in  a  proxi- 
mal direction  bj'  growth  of  the  thrombus  toward  the  heart.  As  the 
cortical  portion  of  the  bone  is  seldom  involved  by  a  tubercular  infarct, 
the  necrosed  area  is  often  overlooked  in  operations  on  tubercular  joints 
unless  the  bone  is  sawn  through.  If  tlie  base  of  the  wedge-shaped  piece 
project  into  a  joint  that  has  been  used,  its  surface  will  be  found  suioothl}'" 
polished  by  the  movements  in  the  joint.  Separation  of  the  sequestrum 
takes  place  more  slowly  than  after  suppurative  osteom^'elitis,  the  process 
requiring  often,  according  to  the  size  of  the  sequestrum  and  the  activity 
of  the  inflammatory  process,  months  and  years  for  its  completion.  If 
the  granulations  which  surround  the  sequestrum  do  not  undergo  cheesy 
degeneration,  the  bone  becomes  imbedded,  and  fits  accurately  into  the 
cavity,  and  if  the  surrounding  zone  of  granulation  is  converted  into 
connective  tissue  it  ma}'  become  per  man  en  tl}'  encapsulated  ;  but  even 
from  such  an  apparently  healed  depot  local  and  general  infection  can 
occur  at  an}'  time. 

4.  The  diffuse  form  of  tuberculous  osteomyelitis  is  quite  rare.     The 


TUBERCULOSIS   OF    BONE.  497 

pathological  and  clinical  characteristics  of  this  form  of  local  tuberculosis 
consist  in  the  rapid  local  extension  of  the  affection  and  the  danger  to 
life  from  general  infection.  On  making  a  longitudinal  section  through 
a  long  bone  aflected  by  diffuse  tuberculous  osteomj-elitis,  we  observe 
conditions  -which  closely  resemble  acute  suppurative  osteomyelitis.  We 
find  large,  irregular,  often  multiple  areas  of  a  j-ellowish-white  infiltration 
with  multiple  foci  of  liquefied  chees}'  material.  The  infection  extends, 
as  in  cases  of  suppurative  osteomyelitis,  along  the  blood-vessels  and 
Haversian  canals  to  the  periosteum,  resulting  in  diffuse  plastic  osteo- 
m3'elitis  with  the  formation  of  irregular,  diffuse  masses  of  bone.  In 
these  cases  there  is  no  tendenc}^  to  limitation  in  the  formation  of 
sequestra,  but  rather  a  tendenc}'  to  spread  indefiniteh',  and  to  invade 
even  the  medullary  tissue  of  the  shaft.  Patients  suffering  from  this 
form  of  tubercular  osteomyelitis  are  exposed  to  the  dangers  of  a  fatal 
general  tuberculosis  if  the  infected  tissues  are  not  removed  Iw  a  timel}' 
and  thorough  operation.  In  operating  it  is  important  to  recognize  this 
form,  since  it  requires  more  radical  measures, — either  amputation  or  verj'^ 
extensive  excisions  of  the  entire  thickness  of  the  affected  bone.  Local 
operations  such  as  will  meet  the  indications  in  the  other  varieties  of 
osteo-tuberculosis  are  of  no  avail.  With  the  exception  of  this  form  of 
tuberculosis  of  bone  the  periosteum  seldom  participates  in  the  tubercular 
Inflammation.  When  the  dry  granulation  form  reaches  the  periosteum, 
a  small,  soft,  elastic,  limited  granulation  swelling  forms, — first  under  the 
periosteum,  later  outside  of  it.  It  is  characterized  by  slow  growth, 
comparativel}'  little  pain,  slight  tenderness,  and  a  tendenc}^  to  remain 
stationary  for  a  long  time.  If,  however,  the  central  focus  has  become 
chees}',  and  the  liquefied  cheesy  material  comes  in  contact  with  the  peri- 
osteum and  the  paraperiosteal  tissues,  a  large  tubercular  abscess  forms 
in  a  short  time.  As  soon  as  the  periosteum  has  been  perforated  the 
cheesy  material  infects  the  connective  tissue,  which  then  takes  an  active 
part  in  the  formation  of  the  tuberculnr  abscess.  Before  such  an  abscess 
spontaneously  ruptures,  the  skin  overlying  it  becomes  tuberculous  and 
presents,  at  the  point  of  perforation,  the  appearance  of  lupus. 

Symptoms  and  Diagnosis. — The  general  symptoms  are  often  no  indi- 
cation of  tlie  existence  or  extent  of  the  local  disease,  as  patients  with 
quite  extensive  osteo-tuberculosis  may  present  ever}-  appearance  of  per- 
fect health.  More  than  ten  years  ago  Konig  called  our  attention  to  the 
fact  that  a  slight  rise  in  the  temperature  is  frequently  present  even  in 
cases  of  limited  local  tuberculosis.  If  the  thermometer  show  a  normal 
morning  temperature,  but  a  slight  rise  toward  evening,  if  not  more  than 
half  a  degree  Fahrenheit,  but  continued  for  weeks,  it  indicates  a  careful 
search  for  a  local  tubercular  focus.     Progressive  anaemia  is   always  an 

32 


498  PRINCIPLES   OF    SURGERY. 

unfavorable  symptom,  as  it  indicates  either  the  presence  of  additional 
foci  in  important  organs  or  accompanies  the  exhaustive  purulent  dis- 
charges after  secondary  infection  with  pus-microbes.  Tiie  occurrence 
of  mixed  infection,  with  or  without  a  direct  infection-atrium,  is  usually 
announced  by  a  high  temperature  and  other  symptoms  of  septic  infection. 
The  local  symptoms  vary  according  to  the  location,  condition,  and  size 
of  the  tubercular  focus  and  the  presence  or  absence  of  complications. 

I.  Pain. — Pain  is  an  almost  constant  symptom,  but  its  intensity  is 
subject  to  great  variation.  Unlike  in  acute  suppurative  osteomyelitis, 
tlie  inflammatorv  product  does  not  give  rise  to  the  same  degree  of 
tension ;  hence  pain  is  not  so  severe.  The  primary  exudation  in  tuber- 
cular inflammation  is  always  scanty,  and  the  inflammatory  product  is 
composed  mostly  of  granulation  tissue  derived  from  pre-existing  cells; 
at  the  same  time  the  surrounding  bone-tissue  becomes  osteoporotic, 
consequently  tension  is  to  a  great  extent  avoided  and  pain  is  either 
slight  or  entirely  absent.  Children  suffering  from  spina  ventosa  com- 
plain of  little  pain,  although  a  phalanx  of  a  finger  ma}'  be  almost 
completely  destro3'ed  by  a  tubercular  osteomyelitis.  In  such  cases  the 
granulation  tissue  is  formed  slowly,  the  compact  layer  of  the  bone  is 
rendered  osteoporotic,  and  generally  yields  to  the  intra-osseous  pressure 
and  expands  perhaps  to  twice  its  normal  thickness ;  pain  is  slight  or 
entirely  absent,  because  no  great  intra-osseous  tension  has  occurred. 
That  tension  or  pressure  greatl}'  aggravates  pain  in  osseous  tuberculosis 
is  one  of  the  most  familiar  fixcts  in  surgery.  Pain  is  promptly  relieved 
in  a  case  of  tubercular  spondylitis  by  suspension  and  rest  in  the  recum- 
bent position,  and  greatly  aggravated  by  flexion  of  the  spinal  column, 
which  necessarily  produces  pressure  upon  the  bodies  of  the  inflamed 
vertebrae.  In  osteo-arthritis  of  the  large  joints  pain  is  relieved  by  rest 
and  extension,  and  is  always  increased  by  use  of  the  limb  or  by  pressing 
the  inflamed  articular  surfaces  against  each  other.  It  maj'  be  stated,  as 
a  rule,  that  the  intensity  of  the  pain  bears  a  direct  relationship  to  the 
acuteness  of  the  inflammatory  process.  The  pain  is  intermittent  and 
more  severe  during  the  night.  The  nocturnal  exacerbation  of  the  pain, 
as  evidenced  in  children  by  restlessness  during  sleep,  moaning,  grinding 
of  teeth,  and  horrible  dreams,  is  often  one  of  the  first  symptoms  which 
excites  suspicion  of  the  existence  of  osteo-tuberculosis.  The  pain  is  not 
always  referred  to  the  seat  of  lesion.  Tubercular  osteomyelitis  of  the 
head  and  neck  of  the  femur  gives  rise  to  pain  in  the  region  of  the  knee- 
joint,  and  children  suffering  from  tuberculosis  of  the  spine  usuall}'  refer 
all  the  suffering  to  the  pit  of  the  stomach  or  to  some  other  part  of  the 
abdomen  supplied  with  nerves  that  take  their  exit  from  the  spinal  canal 
at  a  point  corresponding  to  the  inflamed  vertebra. 


TUBERCULOSIS   OF   BONE.  499 

2.  Tenderness. — The  existence  of  tenderness  over  a  point  corre- 
sponding to  the  tubercular  focus  in  the  interior  of  a  bone  is  one  of  the 
surest  indications  of  the  existence  of  osteo-tuberculosis.  In  many  cases 
of  epiphj-seal  tuberculosis  patients  have  been  treated  for  some  supposed 
lesion  in  the  adjacent  joint,  simply  because  this  sj^raptom  was  not  care- 
full}-  searched  for,  or,  if  discovered,  its  significance  was  misinterpreted, 
lu  such  cases  the  existence  of  a  circumscribed  point  of  tenderness  in  the 
epiphyseal  line  and  the  absence  of  lesions  in  the  joint  will  enable  the 
surgeon  to  locate  accurately  a  focus  in  the  interior  of  a  bone.  If  more 
than  one  focus  is  present  in  the  epiphj-seal  extremity  of  a  long  bone  the 
number  of  tender  points  will  correspond  with  the  number  of  foci  in  the 
bone.  Whether  a  central  focus  in  a  bone  could  be  always  recognized  by 
relying  upon  this  sj-mptom  is  somewhat  doubtful,  but  usually  the  foci 
are  located  sufficiently  near  the  surface  of  the  bone  to  give  rise  to  tender 
points,  which  can  be  readily  located  by  finger  pressure. 

3.  Swelling. — External  swelling  is  absent  until  the  atrophic  layer 
of  compact  bone  yields  to  the  intra-osseous  pressure,  as  maj^  be  seen  in 
advanced  cases  of  spina  ventosa,  or  until  b}'  pressure  atrophy  over  the 
centre  of  the  focus  the  compact  layer  is  perforated,  and  a  soft,  circum- 
scribed, bogg}-  swelling  forms  underneath  the  periosteum.  If  the  granu- 
lation tissue  has  retained  its  vitality  the  extra-osseous  swelling  increases 
very  slowlj-  in  size,  and  there  is  no  tendenc}'  to  diffuse  infection  of  the 
connective  tissue  after  the  granulations  have  reached  the  paraperiosteal 
tissues.  Pseudo-fluctuation  is  generally  present,  and  many  such  granu- 
lating foci  at  this  stage  have  been  carclessl}-  incised  under  the  mistaken 
diagnosis  of  abscess.  If  the  central  focus  has  undergone  caseation 
before  the  periosteum  is  perforated,  then  the  paraperiosteal  tissues 
become  rapidly  infected,  and  a  tubercular  abscess,  such  as  has  been 
described  before,  develops  in  a  short  time.  The  abscess  wanders  away 
fiom  the  place  where  it  originated  in  directions  offering  the  least  resist- 
ance, along  preformed  anatomical  spaces  and  in  obedience  to  the  law  of 
gravitation.  The  size  of  such  an  abscess  is,  absolutely,  no  indication  of 
the  extent  of  the  primar}'^  lesion  in  the  bone,  as  a  minute  focus  Yna.y  be 
the  cause  of  a  large  abscess,  and  a  small  abscess  maj-  mark  the  location 
of  an  extensive  primary  lesion.  (Edema  is  usually  not  well  marked, 
even  if  the  abscess  is  large,  unless  secondar}^  infection  with  p3'ogenic 
microbes  has  occurred.  The  diffuse  form  of  tuberculous  osteomj-elitis  is 
alwa3'S  attended  by  a  plastic  osteomyelitis,  and,  consequently,  the  early 
appearance  of  external  swelling  is  one  of  the  points  to  be  taken  into 
consideration  in  differentiating  between  the  different  forms  of  osteo- 
tuberculosis.  The  swelling  that  attends  tuberculosis  in  bones  deeply 
seated,  as  the  vertebrse,  hip-joint,  and  pelvic  bones,  docs  not  become 


500  PRINCIPLES   OF    SURGERY. 

apparent  until  the  existence  of  a  tubercular  abscess  indicates  the  probable 
seat  of  the  primar}'  lesion, 

4.  Redness. — The  skin  over  a  tubercular  focus  in  the  interior  of  a 
bone  or  over  a  tubercular  abscess  presents  a  normal  appearance  until  it 
has  become  infected  and  shows  other  unmistakable  signs  of  tubercu- 
losis. This  does  not  occur  until  the  granulations  have  permeated  the 
deeper  portions  of  the  skin,  or  until  tlie  caseous  material  has  only  the 
skin  for  its  covering.  Under  such  circumstances  the  skin  presents  a 
dusk3'-red  hue,  owing  to  impaired  capillar}'  circulation,  and  becomes 
more  and  more  attenuated  by  pressure  atrophy  and  destructive  changes 
until  it  finally  yields  to  the  pressure  atrophy  from  beneath,  and  spon- 
taneous evacuation  of  the  contents  of  the  abscess  takes  place.  If  the 
subcutaneous  product  is  composed  of  granulation  tissue  the  undermined 
skin,  after  putrefaction  has  taken  place,  is  destroyed  by  degrees  and  the 
part  presents  the  appearances  of  lupus. 

5.  Atrophy  of  Limb. — Muscular  atrophy  is  almost  a  constant  symp- 
tom in  osteo-tuberculosis  as  well  as  in  tubercular  synovitis.  This  atrophy 
is  not  caused  altogether  by  inactivity  of  the  limb,  and  it  appears  to  be 
due  to  tropho-neurotic  lesions. 

Besides  a  careful  study  of  the  clinical  histor}^  several  diagnostic 
measures  may  be  resorted  to  in  doubtful  cases  to  enable  the  surgeon  to 
make  a  positive  diagnosis. 

Means  of  DifFerentlal  Diagnosis — (a)  Akido  Peurastik. — Exploration 
of  a  doubtful  swelling  with  a  strong  steel  needle  was  introduced  by  Mid- 
deldorpf,  for  the  purpose  of  ascertaining  the  consistence  and  probable 
structure  of  the  tissues  composing  the  swelling.  He  called  this  simple 
procedure  akido  peurastik.  The  presence  of  a  tubercular  focus  in  the 
interior  of  a  bone  can  often  be  demonstrated  by  this  aid  to  diagnosis 
before  an}'  external  swelling  has  appeared.  A  strong  needle  of  a  hypo- 
dermic syringe  can  be  used  for  exploring  a  bone  the  density  of* which 
has  been  diminished  by  chronic  inflammation,  if  this  latter  has  not 
been  followed  by  osteosclerosis.  During  the  active  stage  of  osteo- 
tuberculosis  the  bone  for  a  considerable  distance  around  the  focus  is 
osteoporotic,  and  can  be  readily  penetrated  by  a  strong,  sharp  needle. 
The  exploration  should  be  made  under  strict  antiseptic  precautions. 
The  puncture  is  made  in  the  centre  of  the  tender  area,  and  in  a  direction 
corresponding  to  the  probable  location  of  the  central  focus.  If  tlie 
needle  meet  with  any  considerable  resistance  in  the  bone,  it  is  advanced 
by  rotatory  movements;  the  arrival  of  the  point  in  the  granulating 
centre  or  caseous  focus  is  announced  by  a  sudden  loss  of  resistance. 
By  advancing  the  needle  sufficiently  to  touch  the  opposite  side  of  the 
cavity  its  probable  size  can  be  ascertained. 


TUBERCULOSIS    OF    BONE.  501 

(b)  Explopatopy  Puncture,  with  Aspiration.— If  the  needle  of  an  ex- 
ploratoiy  or  hypodermic  springe  is  used  to  make  the  akido  peurastik, 
exploration  of  the  bone  ma^'  be  followed  by  removing  some  of  the  eon- 
tents  of  the  cavity  for  examination  by  aspiration.  If  the  tubercular 
product  has  undergone  caseation  and  liquefaction  some  of  the  cheesy 
material  can  be  removed  by  aspiration,  and  the  nature  of  the  lesion  may 
then'  be  revealed  by  positive  demonstration.  If  still  further  evidence  is 
required,  a  guinea-pig  may  be  inoculated  with  the  same  needle,  which 
still  contains  enough  of  the  material  to  produce  a  positive  result  in  the 
animal.  If  the  cavity  contain  granulation  tissue  little  fragments  of  this 
can  be  drawn  into  the  needle,  and  with  these  inoculation  experiments  for 
diagnostic  purposes  can  be  made.  In  tubercular  necrosis  it  may  be  pos- 
sible to  detect  the  presence  of  the  sequestrum  and  ascertain  its  mobility 
by  exploratory  puncture.  If  a  tubercular  abscess  has  formed,  the  char- 
acter of  the  contents  of  the  swelling  may  be  ascertained  by  using  the 
exploratory-  s^^ringe,  and  the  nature  of  the  primary  cause  demonstrated, 
if  need  be,  by  injecting  the  material  aspirated  into  the  subcutaneous 
tissue  or  peritoneal  cavit}-  of  a  guinea-pig.  In  the  differential  diagnosis 
of  tuberculosis  of  ])one,  it  is  necessary  to  exclude  synovial  tuberculosis, 
sarcoma,  echinococcus-C3'st,  rachitis,  suppurative  osteomyelitis,  and 
syphilis.  Many  cases  of  primary  tuberculosis  of  bone  have  been  mistaken 
for  synovial  tuberculosis,  and  vice  versa.  Primary  tuberculosis  of  bone 
frequently  results  in  contractures  of  joints  without  direct  implication  of 
the  joint,  and  this  has  often  led  to  a  wrong  diagnosis.  In  primary  syno- 
vial tuberculosis  the  first  pathological  changes  occur  in  the  joint,  and  no 
tender  points  will  be  found  in  the  epiph^'seal  regions.  In  osteo-tubercu- 
losisnot  complicated  b}^  an  extension  of  the  disease  to  the  adjacent  joint, 
the  first  S3-mptoms  are  referred  to  the  lesion  existing  in  the  interior  of 
the  bone,  and  it  is  usually  not  difficult  to  ascertain  the  existence  of  cir- 
cumscribed points  of  tenderness  which  correspond  to  the  location  of 
the  foci.  Periosteal  sarcoma  is  from  the  beginning  an  extra-osseous 
product.  Central  sarcoma,  as  a  rule,  increases  more  rapidly  in  size  than 
a  tuliercular  swelling,  and  is  often  the  seat  of  pulsations  and  a  blowing 
sound  which  can  be  heard  by  auscultation.  Central  sarcoma  is  often  the 
cause  of  a  pathological  fracture,  while  this  accident  is  exceedingl}'  rare 
in  osteo-tuberculosis.  Echinococcus  of  bone  is  an  exceedingly  rare 
aflfection,  but,  as  it  ni;.}'  simulate  osteo-tuberculosis,  differential  diagnosis 
must  be  based  on  an  exploratory  puncture,  which  will  yield  a  clear  serum 
containing  the  characteristic  booklets  in  the  former  instance,  and  granu- 
lation tissue  or  the  products  of  caseous  degeneration  in  the  latter. 
Rachitis  gives  rise  to  swelling  and  pain  in  the  epiphyseal  regions;  but 
this  affection  is  not  limited  to  one  or  two  bones,  and  affects  almost  ever}' 


502  PRINCIPLES    OF    SURGERY. 

boue  in  the  body  alike.  Epiphyseal  multiple  osteomyelitis  is  an  acute 
or,  at  least,  subacute  affection,  and  results  early  in  the  formation  of  puru- 
lent foci,  and  is  often  attended  by  epiphyseolysis.  The  virus  of  syphilis 
has  a  special  predilection  for  the  periosteum,  while  this  structure  is 
almost  immune  to  primary  tubercular  atlections.  In  95  out  of  every  100 
cases  chronic  inflammation  in  bone  means  tuberculosis,  and,  unless  there 
are  special  reasons  which  should  render  the  diagnosis  doubtful,  it  is  safe 
to  adopt  a  treatment  adapted  for  tubercular  osteomj'elitis  in  almost 
every  case  where  the  symptoms  point  to  a  chronic  inflammation  and  the 
existence  of  a  tumor  or  parasitic  growth  can  be  excluded. 

Prognosis. — On  tlie  whole,  the  prognosis  is  more  favorable  in  cases 
of  osteo-tuberculosis  than  if  the  tubercular  infection  is  located  in  the 
skin,  a  joint,  lymphatic  gland,  or  an}-  of  the  internal  organs.  Spontaneous 
healing  of  a  tubercular  focus  in  bone  is  possible  under  favorable  con- 
ditions. Everything  that  adds  to  the  patient's  strength  and  power  of 
resistance  to  the  microbic  infection  adds  to  the  possibilit}'  of  such  a 
favorable  termination.  If  the  patient  is  well  nourished,  and,  above  all, 
if  the  blood  is  in  a  normal  condition,  limitation  of  the  disease  may  occur 
before  caseation  has  taken  place  ;  and  if  cheesy  material  has  formed,  and 
it  can  be  removed  b}^  operative  interference,  the  prospects  of  a  perma- 
nent recover}'  are  good.  It  must  be,  however,  admitted  that  every  person 
who  has  sufl^'ered  from  an  attack  of  osteo-tuberculosis  during  childhood 
or  youth,  even  if  an  apparent  perfect  cure  has  been  effected  spontaneously' 
or  by  operative  measures,  is  always  in  danger  of  becoming  the  subject 
of  re-infection  at  any  subsequent  time.  The  spores  of  the  bacillus  of 
tuberculosis  may  remain  in  a  latent  condition  for  an  indefinite  period  of 
time  in  the  cicatrized  primary'  lesion,  to  become  a  cause  of  subsequent 
danger  as  soon  as  the  local  or  general  conditions  enable  them  to  exercise 
their  patliogenic  properties.  Healing  by  cicatrization  is  possible  in  the 
small  granulating  foci  so  long  as  the  coagulation  necrosis  is  limited  and 
no  caseation  has  occurred.  In  such  cases  the  embryonal  cells  are  con- 
verted into  permanent  connective  tissue  and  the  small  fragments  of  bone 
are  removed  b}-  absorption,  while  the  bone  around  the  cicatrix  becomes 
sclerosed.  If  caseation  has  occurred,  but  the  chees}'  material  has  not 
undergone  liquefaction,  encapsulation  of  the  tubercular  product  can  take 
place  b}'  the  wall  of  granulation  tissue  lining  the  cavit}'  becoming  con- 
verted into  cicatricial  tissue,  forming  a  capsule,  which,  for  the  time  being 
at  least,  mechanically  prevents  the  local  extension  of  the  disease.  Small 
sequestra  may  become  imbedded  in  a  connective-tissue  capsule  in  u 
similar  manner.  If  the  sequestrum  is  large,  it  will  act  like  every  other 
foreign  infected  bodj',  and  sooner  or  later  require  an  operation  for  its 
extraction.     If  the  tubercular  process  has  extended  to  a  joint,  the  prog- 


TUBERCULOSIS    OF    BONE.  503 

nosis  is  more  grave,  and  the  chances  for  a  spontaneous  recovery  are 
much  diminished.  The  prognosis  is  always  more  grave,  other  things 
being  equal,  if  the  bone  affected  is  so  located  that  removal  of  the  pri- 
mary focus  by  operative  treatment  is  anatomically  impossible.  The 
danger  to  life  and  the  probabilitj-  of  local  extension  are  always  greater 
if  the  granulation  tissue  has  been  destroyed  by  coagulation  necrosis  and 
caseation,  as  the  granulation  tissue  is  one  of  the  means  by  which  regional 
and  general  infection  are  prevented.  The  danger  to  life  is  imminent  if  a 
large  tubercular  abscess  has  become  infected  with  pus-microbes,  as  the 
secondary  infection  results  in  destruction  of  the  granulation  tissue  lining 
the  cavity,  which  favors  the  local  and  general  extension  of  the  tuber- 
cular infection  and  at  the  same  time  brings  sepsis,  exhaustion  from  pro- 
fuse suppuration,  and  am3loid  degeneration  of  important  internal  organs 
as  additional  elements  of  danger.  The  prognosis  is  always  more  grave 
in  persons  advanced  in  years  than  in  children,  as  limitation  of  the  dis- 
ease occurs  more  frequently'  in  the  latter. 

Treatment. — The  medical  treatment  in  patients  suffering  from  osteo- 
tuberculosis  must  be  tonic  and  supporting.  Dietetic  and  hygienic  treat- 
ment is  of  more  value  than  the  administration  of  drugs.  Sea-bathing 
and  change  of  climate  will  often  accomplish  more  than  bitter  tonics,  iron, 
quinine,  arsenic,  and  codliver-oil.  The  local  treatment,  sliort  of  a  radical 
operation,  must  consist  in  the  use  of  such  means  as  will  aid  the  natural 
resources  in  effecting  limitation  of  the  tubercular  process,  of  which  the 
most  important  is 

I.  Physiological  Rest. — The  importance  of  securing  for  the  inflamed 
part,  as  near  as  can  be  done  by  mechanical  support,  absolute  physio- 
logical rest  cannot  be  overestimated.  The  process  of  repair  in  a  tuber- 
cular focus  often  meets  with  great  and  insurmountable  difficulties.  The 
embryonal  cells,  of  low  vitality  almost  from  the  beginning,  are  poisoned 
as  soon  as  born  with  the  ptomaines  of  the  bacillus  of  tuberculosis,  and 
consequently  are  converted  into  tissue  of  a  higher  type  only  under  the 
most  favorable  conditions.  The  non-vascularity  of  the  tubercle  is  an- 
other cause  why  the  inflammatory  product  so  seldom  takes  an  active  part 
in  the  process  of  repair.  The  first  indication  in  the  treatment  of  a  tuber- 
cular osteomyelitis  is  to  secure  for  the  part  a  favorable  condition  of  the 
circulation,  which  can  only  be  done  by  securing  rest.  The  most  efficient 
way  to  procure  rest,  not  only  for  the  diseased  part,  but  for  the  entire 
body,  is  to  confine  the  patient  to  bed  ;  but,  as  these  affections  are  noted 
for  their  chronicity  for  months  and  years,  enforced  rest  b}-  this  method 
would  seriously  impair  the  general  health,  and  on  this  account  it  is  ad- 
visable, in  the  majority'  of  cases,  to  resort  to  one  of  the  numerous 
mechanical  appliances  which  will  immobilize  the  part ;  while,  at  the  same 


504  PRINCIPLES    OF    SUKGERY. 

time,  the  patient  can  avail  himself  of  tlie  benefits  to  be  derived  from 
out-door  air  and  change  of  scenerj-  and  surroundings. 

In  tuberculosis  of  the  spine  Sa3're's  plaster-ot'-Paris  jacket,  applied 
while  the  patient  is  partly  suspended,  answers  a  more  useful  purpose 
than  any  of  the  numerous  complicated  apparatuses  which  have  been  as 
j'et  devised.  To  appl3-  the  jaclvet  properlj^  requires  a  great  deal  of  ex- 
perience and  the  exercise  of  considerable  skill.  In  man}-  communities 
this  method  of  treatment  has  become  unpopular,  both  among  physicians 
and  the  laity,  from  the  bad  results  caused  by  impro[)er  application  of  the 
jacket.  H^-perextension  must  be  avoided,  and  the  patient  must  be 
instructed  to  extend  himself  only  until  pain  is  relieved,  and  not  beyond 
this  point.  The  bou}'  ])ronunence  at  the  seat  of  curvature  must  be 
carefiill}'  protected  against  pressure  b}'  applying  on  each  side  a  pad 
sufficiently^  thick  to  prevent  contact  of  the  projecting  spinous  processes 
with  the  plaster  cast.  The  plaster  bandages  themselves  must  be  applied 
smoothly,  so  that  after  extension  is  removed  the  jacket  will  closel}'^  fit 
the  unequal  surface  of  the  bod}'.  Another  matter  of  great  importance 
is  to  see  the  patient  from  time  to  time,  in  order  to  determine  whether 
the  jacket  causes  injurious  pressure  at  an}-  point,  which,  if  this  should 
be  the  case,  is  remedied  at  once,  either  b^^  cutting  out  that  portion  of 
the  jacket  which  has  caused  the  decubitus  or  by  applying  a  new  one.  In 
tuberculosis  of  any  of  the  bones  of  the  extremities  rest  can  be  secured 
most  efficientl}'  by  immobilizing  the  limb  in  a  plaster-of-Paris  dressing. 
The  splint  must  always  include  one  or  more  of  the  adjacent  joints. 
Undue  constriction  of  the  limb  is  prevented  b}-  interposing  between  it 
and  the  splint  a  thin  layer  of  salicylized  cotton.  If  the  disease  aflTect 
any  of  the  bones  of  tlie  lower  extremities  the  patient  must  not  be 
allowed  to  walk  without  crutches. 

2.  Ignipuncture. — During  the  early  stages  of  osteo-tuberculosis  excel- 
lent results  have  l)een  obtained  b}-  ignipuncture, — a  method  of  treatment 
devised  a  few  years  ago  by  Richet.  If  a  tubercular  focus  can  be  accu- 
ratel}'  located,  this  method  of  treatment  should  receive  a  trial,  as  it  is 
not  attended  by  any  risks  and  frequently  effects  a  permanent  cure.  The 
field  of  opei'ation  is  thoroughly  disinfected,  and,  with  the  needle-point  of 
a  Paquelin  cautery  heated  to  a  dull  or  red  heat,  the  soft  tissues  and 
bone  are  perforated.  In  making  the  perforation  it  is  necessary  to  advance 
the  point  slowly,  and  to  remove  it  from  time  to  time,  and  revive  the 
heat  in  order  to  prevent  impaction  of  the  point.  The  entrance  of  the 
instrument  in  the  cavity  can  be  readily-  felt,  as  resistance  at  that  moment 
is  suddenly  diminislied.  The  therapeutic  effect  of  ignipuncture  is 
threefold :  1.  The  tunnel  made  establishes  free  drainage,  and  relieves 
prompth'  the  intra-osseous  tension.     2.  At  least  a  portion  of  the  in- 


TUBERCULOSIS    OF    BONE.  505 

fected  tissue  is  destroj-ed  I)}-  the  heat.  3.  A  plastic  osteoni3'elitis  is 
excited  in  the  vicinity  of  the  track  and  in  the  cauterized  portion  of  the 
cavit3',  which  exerts  a  favoral)le  influence  in  bringing  about  limitation  of 
the  disease,  or  even  in  effecting  a  final  cure.  Through  the  opening  made 
iodoform  can  be  introduced  into  the  cavity,  which  ort'ers  additional  ad- 
vantage in  treating  osseous  foci  successful!}'  b}'  this  pressure.  To  insure 
a  successful  issue,  it  is  ahsolutehj  necessary  to  prevent  infection  with  pus- 
microhes  through  the  opening  by  making  the  operation  under  strict  anti- 
septic precautions,  and  protecting  the  puncture  with  an  efficient  antiseptic 
absorbent  dressing  until  it  is  completely  closed  by  cicatrization  and  epi- 
dermization.  Ignipunctnro  is  most  useful  in  the  treatment  of  accessible 
foci  in  the  ei)iphyseal  extremities  of  the  long  bones  and  during  the  early 
stages  of  tuberculosis  of  the  wrist  and  tarsus.  In  incipient  tuberculosis 
of  the  tarsus  I  have  repeated}}'  obtained  a  satisfactory  and  permanent 
result  by  making  an  opening  through  the  entire  tarsus  from  side  to  side, 
in  a  line  of  the  disease,  by  inserting  the  point  from  each  side,  the  two 
tunnels  meeting  in  the  centre.  Ignipuncture  always  relieves  the  pain 
promptl}',  and  the  track  made  is  completel}'  closed  by  permanent  tissue 
in  the  course  of  a  few  weeks. 

3.  Radical  Operation — (a)  Removal  of  Limited  Foci. — The  radical 
treatment  of  tuberculosis  of  bone  consists  in  the  complete  removal  of 
the  infected  tissues  b}'  operative  interference.  The  success  which  follows 
this  treatment  is  most  marked  in  cases  where  caseation  has  not  taken 
place, — that  is,  in  the  granulating  form, — and  in  other  forms  where  the 
operation  is  performed  before  extensive  secondar}-  pathological  con- 
ditions have  occurred.  The  operation  is  indicated  as  soon  as  a  positive 
diagnosis  can  be  made,  and  after  the  milder  measures  have  proved  use- 
less in  arresting  the  progress  of  the  disease.  Timely  surgical  inter- 
ference in  osteo-tuberculosis  is  not  onl}-  calculated  to  become  the  surest 
means  of  preventing  general  infection,  but  it  also  has  for  its  object  the 
limitation  of  the  disease  by  the  removal  of  tlie  primary  cause,  and  by 
accomplishing  these  objects  it  becomes  at  once  a  prophylactic  as  well  as 
a  curative  measure.  If  a  tubercular  focus  or  foci  can  be  removed  by  a 
radical  operation  before  the  adjacent  joint  has  become  infected,  then  the 
operation  has  not  onl}-  been  successful  in  effecting  a  permanent  cure,  but 
it  has  also  been  instrumental  in  preventing  the  extension  of  the  disease 
to  the  joint.  If  the  operation  is  undertaken  at  a  time,  as  it  should  be, 
before  an}-  external  swelling  has  appeared,  the  surgeon  must  be  guided 
in  finding  the  focus  by  searching  for  tender  points,  aided,  if  necessary, 
by  exploratory  punctures.  As  in  epiphyseal  tuberculosis  the  foci  are 
always  near  n  joint,  the  incision  for  exposing  the  bone  should  be  made  in 
such  a  manner  as  to  avoid  opening  tlie  joint.     If  the  focus  is  so  close  to 


506  PRINCIPLES    OF    SURGERY. 

the  joint  as  to  make  it  necessary  to  remove  bone  underneath  the  inser- 
tion of  tlie  capsule  or  ligaments  of  the  joint,  it  is  advisable  to  lift  the 
periosteum  with  the  joint  structures  from  tlie  bone  to  some  distance  from 
the  incision,  and  in  this  manner  to  avoid  injury  to  the  joint.  The  bone 
overlying  a  tubercular  abscess  is  usually  softened  and  easily  removed 
with  a  small,  round  chisel.  The  limb  should  always  be  rendered  blood- 
less by  using  Esmarch's  constrictor,  so  that  the  opei'ator  can  identify  the 
tissues  as  they  are  being  removed  during  the  operation.  If,  after  tunnel- 
ing the  bone  for  a  considerable  distance,  the  focus  is  not  found,  it  is 
advisable  to  make  from  this  track  exploratory  punctures  in  different 
directions  with  a  small  perforator  until  the  cavity  is  found,  which  is  then 
freely  exposed  with  the  chisel.  As  soon  as  this  has  been  done  the  sharp 
spoon  is  used,  with  which  the  necrosed  bone,  granulation  tissue,  or  cheesy 
material  is  removed.  The  osteoporotic  bone  in  the  immediate  vicinity 
of  the  cavity  is  removed  in  a  similar  manner,  and  the  surgeon  must 
assure  himself,  by  repeated  examinations  of  the  tissue  removed,  that 
healthy  tissue  has  been  reached  before  the  sharp  spoon  is  laid  aside. 

If  any  doubt  remain  whether  all  of  the  infected  tissue  has  been 
removed,  it  is  better  to  resort  to  ignipuncture,  perforating  the  bone  at 
different  points  to  the  depth  of  a  few  lines  with  the  sharp  point  of  a 
Paquelin  cauterj^  in  addition  to  the  curetting.  This  procedure  will 
destroy  at  least  some  of  the  bacilli  which  might  have  remained,  and  will 
incite  a  plastic  osteomyelitis  that  will  effectually  resist  the  pathogenic 
action  of  such  microbes  that  still  remain.  After  the  cavity  has  been 
thoroughl}-  irrigated  with  an  antiseptic  solution  it  is  dried,  iodoformized, 
and  packed  witli  antiseptic  decalcified  bone-chips.  The  periosteum  is 
separately  sutured  over  bone-packing,  sufficient  space  being  left  to  insert, 
at  the  low  angle  of  the  wound,  a  few  threads  of  catgut  to  serA^e  as  a 
capillary  drain.  The  remaining  tissues  are  included  in  the  superficial 
sutures  and  an  antiseptic  dressing  applied.  The  limb  must  be  immo- 
bilized by  applying  a  well-padded  posterior  si)lint.  If  all  the  infected 
tissues  have  been  removed,  and  no  infection  with  pus-microbes  has  taken 
place  during  or  after  the  operation,  the  wound  unites  under  one  dressing 
in  from  one  to  two  weeks,  and  the  definitive  healing  of  the  cavity  is 
completed  in  the  course  of  three  to  six  weeks,  according  to  the  con- 
dition and  age  of  the  patient  and  the  size  of  the  cavity.  The  packing  of 
such  cavities  with  iodoformized  decalcified  bone-chips  is  an  important 
element  in  the  prevention  of  a  local  recurrence  and  general  infection. 
Should  suppuration  follow  the  operation,  secondar}'  implantation  with 
decalcified  bone-chips  can  be  done  successfully  as  soon  as  suppuration 
has  ceased,  and  the  cavit}^  can  be  made  thoroughly  aseptic. 

(b)  Excision  of  Portion  of  Shart. — This  operation  is  only  indicated 


TUBERCULOSIS    OF    JOINTS.  507 

in  some  cases  of  diffuse  tubercular  osteomyelitis  where  amputation  is 
considered  unneeessar3\  Extirpation  of  the  entire  bone  affected  is  fre- 
quently necessary  in  tuberculosis  of  the  wrist  and  ankle-joint. 

(c)  Amputation. — Amputation  is  often  the  only  choice  in  the  treat- 
ment of  diffuse  tuberculous  osteomyelitis,  as  it  offers  the  only  chance  to 
effect  complete  eradication  of  the  disease,  and  to  protect  the  patient 
against  general  infection.  It  is  contra-indicated  in  the  other  forms  of 
osteo-tuberculosis,  unless  complicated  by  tuberculosis  of  an  adjacent 
joint,  and  even  in  such  instances  it  is  limited  to  cases  that  have  passed 
bej'ond  the  reach  of  a  tj'pical  or  atypical  resection. 

TUBERCULOSIS   OF   JOINTS. 

Tuberculosis  of  joints,  chronic  fungous  arthritis,  strumous  arthritis, 
and  tumor  albus  are  terms  that  even  now  are  being  used  S3'nonymoiisly 
to  indicate  a  form  of  inflammation  of  joints  which  clinicallj'  is  char- 
acterized by  its  chronic  course  and  the  absence  of  acute  signs  of  inflam- 
mation. This  affection  is  b}-  far  the  most  common  joint  disease,  so  much 
so  that  Konig  states  that  in  surgical  clinics  the  surgeon  will  have  100 
cases  of  tuberculosis  of  the  joints  to  deal  with  to  one  of  the  other  classes 
of  inflammation,  such  as  gonorrhoeal,  S3'pliilitic,  suppurative,  osteomj^e- 
litic,  rheumatic,  or  the  metastatic  inflammations  subsequent  to  acute 
infectious  diseases. 

Etiology. — We  distinguish,  as  to  origin,  between  primary  synovial 
and  primary  osteal  tuberculosis  of  the  joints.  If  the  primary  focus  is 
in  the  bone  the  disease  usually  extends  to  the  joint  b}'  direct  extension 
of  the  process  to  the  structures  of  the  joint.  In  primary  synovial 
tuberculosis  the  bacillus  is  conveyed  through  the  circulation,  and  locali- 
zation takes  place  in  the  synovial  membrane. 

Max  Schiiller  proved  experimentall}',  in  animals  infected  with  tubercle 
bacilli, — for  instance,  through  the  respiratory  tract, — that  a  slight  trau- 
matism to  a  joint  would  determine  localization,  b}' way  of  the  circula- 
tion, to  the  injured  part,  and  that  a  tubercular  synovitis  or  panarthritis 
would  follow.  The  same  author  makes  the  statement,  based  on  the 
results  of  his  experiments,  that  a  slight  injury  to  a  joint  in  a  person  who 
has  bacilli  floating  in  his  blood  would  determine  localization,  commonly 
in  the  form  of  a  S3'novial  tuberculosis.  Clinically,  tuberculosis  of  joints 
has  been  ti'i^ced  in  56  per  cent,  of  the  cases  to  traumatism  hy  a  direct 
blow  to  a  joint,  or  distortion,  or  overexertion.  It  is  characteristic  that 
the  traumatism  is  always  slight;  a  severe  injury,  causing  intra-articular 
fracture,  is  very  rarel}'  followed  by  tuberculosis,  for  the  same  reasons 
that  severe  injuries  do  not  produce  the  disease  in  bone  and  other  organs. 
It  may  be  stated  that,  as  to  the  relative  frequency  of  the  two  forms  of 


508  PRINCIPLES    OF    SUKGEKV. 

infection,  it  has  been  sliown  that  primary  osteal  tuberculosis  occurs  two 
or  tliree  times  as  often  as  tlie  prinuuy  synovial.  Tuberculosis  of  joints 
is  always  closely  related  to  the  same  disease  in  bone,  because,  when  it 
does  not  follow  the  latter  as  a  secondary  lesion,  the  primary  synovial  not 
seldom  implicates  the  adjacent  bone  from  the  direct  extension  of  the 
infection  from  the  fungous  synovial  membrane  to  tlie  subjacent  bone 
structure.  Synovial  tuberculosis  is  more  frequent  in  the  adult  than  in 
children.  Primary  infection  of  a  joint  is  possible  only  through  a  wound, 
as  in  the  case  referred  to  under  the  head  of  Inoculation-Tuberculosis. 
Tubercular  infection  of  an  intact  joint  presupposes  the  entrance  of  the 
bacillus  of  tuberculosis  through  tlie  respiratory-  tract  or  alimentar}^ 
canal,  or  througli  some  external  infection-atrium  into  the  systemic  circu- 
lation, or  the  dilfusion  of  bacilli  through  the  same  channel  from  some 
pre-existing  tubercular  focus,  and  the  localization  of  floating  bacilli  in 
the  synovial  meml)rane  by  capillary  embolism  or  by  mural  implantation. 
A  simple  tubercular  nodule  over  the  surface  of  the  synovial  membrane 
may  lead,  in  a  com[)arativel3^  short  time,  to  diffuse  tuberculosis  over  the 
entire  surface  of  the  joint  b}-  local  dissemination  of  the  microbes,  in 
which  the  synovial  fluid  and  the  movements  of  the  joint  play  an  impor- 
tant part.  In  the  osteal  form  of  tuberculosis  of  joints  the  infection 
extends  from  the  bone  to  the  joint  at  once,  in  cases  where  the  primary 
disease  is  the  result  of  infarction,  as  the  base  of  the  wedge-shaped  piece 
of  the  necrosed  bone  communicates  direetl}'  with  the  joint;  while  infec- 
tion of  the  joint  occurs  secondarily,  in  cases  of  granulating  foci  and 
tubercular  necrosis,  by  perforation  of  the  tubercular  product  into  the 
joint.  When  the  foci  are  located  close  to  the  articular  cartilage,  this 
must  be  destroyed  before  the  joint  is  invaded,  the  cartilage  forming  a 
barrier  that  may  sometimes  prove  sufficient  to  resist  invasion.  In  case 
a  focus  is  located  at  the  surface  of  a  joint,  Avhere  the  bone  is  not  covered 
with  articular  cartilage,  the  thin  periosteum  and  the  synovial  membrane 
covering  it  are  more  easily  perforated,  and  consequently  secondary  syno- 
vial tuberculosis  is  more  liable  to  follow.  The  most  complicating  condi- 
tion ma^'  arise  if  a  tubercular  focus  is  located  at  the  insertion  of  the 
capsule  of  a  joint.  It  may  then  open  into  and  outside  of  the  joint 
simultaneously,  or  the  one  or  the  other,  the  integrity  of  the  joint  de- 
pending on  the  few  lines  of  space  occupied  b}'  the  cnpsule. 

Pathology  and  Morbid  Anatomy. — In  synovial  tul)erculosis  a  series 
of  pathological  changes  are  initiated  in  which  all  the  structures  of  the 
joint  are  (inally  concerned,  namel}',  the  sjaiovial  membrane,  para-S3-novial 
tissues,  articular  cartilage,  and  lastly  the  bone.  The  tubercle-nodule  in 
the  S3'novial  membrane  presents,  under  the  microscope,  the  same  histo- 
logical structure  as  in  other  tissues.     When  the  synovial  surface  has 


TUBERCULOSIS   OF   JOINTS.  -"iOD 

become  the  seat  of  diffuse  tuberculosis,  the  tissues  undergo  tho  same 
pathological  changes  as  during  the  first  stage  of  tuberculosis  in  other 
organs,  and  it  is  the  charncteristic  granulation  tissue  that  has  given  to 
this  form  of  arthritis  the  names  of  fungous  synovitis  and  synovitis  hyper- 
plastica  granulosa.  During  the  early  stages  of  the  disease  the  surgeon 
meets  with  two  distinct  varieties;  in  one  the  tubercular  infection  pro- 
duces a  pulpy  condition  of  the  entire  S5niovial  sac,  with  little  or  no  effu- 
sion into  the  joint,  the  swelling  being  due  entirely  to  the  presence  of 
a  thick  layer  of  granulation  tissue, — the  true  tumor  alhus  of  the  old 
writers.  This  form  of  tuberculosis  gives  rise,  at  an  early  stage,  to  exten- 
sive deformity  of  the  joint,  flexion,  rotation,  and,  in  the  case  of  the 
knee-joint,  partial  dislocation  of  the  tibia  backward.  In  the  other  variet}' 
the  fungous  granulations  are  less  marked,  but  a  copious  effusion  takes 
place  into  the  joint,  which  simulates  a  catarrhal  synovitis,  until  time 
and  tlie  effect  of  treatment  enable  the  surgeon  to  make  a  correct  differ- 
ential diagnosis.  In  tliis  form  Konig  assures  us  tliat  he  has  never 
observed  a  tendency  to  flexion  or  any  other  form  of  displacement  of  the 
joint  surfaces.  If  suppuration  take  place,  which  is  not  very  often  the 
case,  it  begins  in  the  granulations  which  cover  the  synovial  membrane, 
and  the  pus  accnmuiates  in  the  cavity  of  the  joint  until  perforation 
of  the  capsule  takes  place.  During  the  suppurative  process  the  granu- 
lations are  destroyed  and  the  tubercular  infection  penetrates  deeper, 
and,  as  during  the  destructive  process  blood-vessels  are  destroyed,  the 
patient  is  exposed  to  the  additional  risks  of  general  infection.  If  a 
tubercular  joint  open  spontaneously',  or  is  not  incised  under  the  strictest 
antiseptic  precautions,  the  additional  infection  from  without  leads  to  the 
most  serious  consequences,  as  under  these  circumstances  the  pus-microbes 
are  brought  in  contact  with  a  surface  that  has  been  admirabl}-  prepared 
by  the  bacillus  of  tuberculosis  for  suppurative  and  septic  processes. 

Pathological  Varieties  of  Joint  Tuberculosis.— TnV>ercuhir  inflamma- 
tion of  the  synovial  membrane  of  joints  results  in  different  gross 
pathological  conditions  that  serve  as  a  basis  for  classification  into  :  1. 
Pannous  hyperplastic  synovitis.  2.  Tuberous  hyperplastic  synovitis 
or  papillomatous  plastic  synovitis.  3.  Granular  or  fungous  hyperplastic 
synovitis.     4.   Tuberculnr  articuhir  emiiyema. 

I.  Pannous  Hyperplastic  Synovitis. — The  tubercle-nodules  are  ex- 
ti'emely  small,  rarely  visible  to  the  naked  e3-e,  and  wideh'  disseminated 
over  the  entire  or  greater  portion  of  the  S3'novial  sac.  The  synovial 
membrane  is  only  moderatelj'  thickened,  but  quite  vascular.  From  the 
border  of  the  cartilage  a  thin,  vascular  layer  of  granulations  approaches 
the  centre  of  the  surfice  of  the  joint  somewhat  in  the  manner  a  pannus 
invades  the  cornea.    Tiiis  form  of  synovitis  was  first  described  b}'  Hueter. 


510  PRINCIPLES    OF    SURGlJiY. 

2.  Tubercular  Plastic  Synovitis  or  Papillomatous  Plastic  Synovitis. — 

The  tubeiLMihir  iiilluniination  results  in  the  foniuitioii  of  sub-syuovinl 
fibrous  masses,  which  may  attain  the  size  of  a  walnut,  protruding  into 
the  joint  and  filling,  for  example,  the  supra-patellar  recess  of  the  knee- 
joint,  with  simple  irritative  synovitis  or  pannous  synovitis  in  the  rest 
of  the  cavity.  The  tubercular  infection  in  such  cases  is  limited,  and  the 
removal  of  the  fibrous  swelling  results  in  a  permanent  cure.  In  other 
oases  of  the  same  U'pe  of  inflammation  the  foci  are  numerous,  resulting 
in  papillomatous  plastic  synovitis  where  the  whole  inner  surface  of  the 
synovial  membrane  is  covered  with  sessile  or  pedunculated  papillomatous 
growths,  small  and  rather  uniform  in  size,  some  of  which  may  become 
detached,  w^hen  they  constitute  the  so-called  rice-bodies. 

3.  Granular  Fungous  Hyperplastic  Synovitis. — In  this  variety  of  joint 
tuberculosis  the  synovial  membrane  is  atiected  throughout,  being  con- 
siderabl}'  thickened  and  hypersemic,  and  covered  b}^  a  more  or  less  thick 
layer  of  velvety  granulations.  The  ligaments  and  para-articular  struct- 
ures are  affected  at  a  comparatively  early  stage,  and  thus  is  formed  the 
thick,  oedematous  mass  of  tissue,  usuall}^  of  a  gelatinous  appearance,  in 
which  here  and  there  cheesy  foci  are  found. 

Anj^  of  the  above-named  forms  of  tubercular  synovitis  may  give  rise 
to  the  transudation  of  serum  or  a  sero-fibrinous  fluid  into  the  joint, — 
the  tubercular  hydrops  of  Konig.  As  a  rule,  the  serous  effusion  is  most 
copious  in  cases  where  the  synovial  membrane  has  undergone  the  least 
change ;  that  is,  in  pannous  hj'perplastie  s^-novitis.  In  tuberous  and 
papillomatous  sjuiovitis  the  eflfusion  is  usually  scant}',  and  in  fungous 
synovitis  attended  by  the  formation  of  massive  granulations  it  is  absent, 
as  a  rule.  The  effusion  into  the  joint,  in  tubercular  hydrops,  is  either  a 
thin,  clear  synovia,  or  it  is  rendered  slightl}-  turbid  from  the  admixture 
of  leucocytes  and  the  products  of  coagulation  necrosis,  or,  if  the  effu- 
sion is  of  a  sero-flbrinous  character,  it  contains  shreds  of  fibrin.  The 
rice-bodies  {corpora  amylacese)^  so  frequently  found  in  tubercular  joints, 
are  composed  of  dense  masses  of  fibrin  or  they  are  detached  papillo- 
mata.  That  these  bodies  are  a  tubercular  product  I  have  repeatedly 
satisfied  myself  by  inoculation  experiments. 

4.  Tubercular  Articular  Empyema  {Konig). — The  tubercular  abscess 
of  joints  is  an  advanced  stage  of  the  other  varieties  of  tubercular 
synovitis.  The  inside  of  the  capsule  is  covered  with  loosely-adherent 
tuberculous  membrane,  similar  to  that  in  tubercular  abscesses.  The 
superficial  granulations  which  compose  this  membrane  have  undergone 
degenerative  changes.  Outside  of  this  membrane  the  tissues  are 
diff'usel}'  infiltrated  Avith  miliary  tubercles,  but  the  infection  does  not 
extend  bej'ond  the  S3-novial  membrane.     The  fluid  in  the  joint,  like  in 


TUBERCrLOSIS    OF    JOINTS.  51 1 

all  tubercular  abscesses,  is  not  pus,  but  serum,  in  which  we  find  suspended 
the  products  of  coagulation  necrosis.  With  the  extension  of  the  tuber- 
cular process  be3'ond  the  limits  of  the  synovial  sac,  the  articular 
cartilage,  and,  finall}^  the  bone,  are  successiA^ely  attacked.  The  articular 
cartilage  takes  no  active  part  in  the  inflammatory  process;  it  is  detached 
and  removed  b}'  the  granulations.  An  osseous  focus  in  contact  with 
the  cartilage  usuall}'  makes  a  circular  defect  througli  which  the  granu- 
lations or  cheesy  material  can  be  seen.  The  cartilage  covering  a  tuber- 
cular infarct  is  rapidl}^  destroyed,  and  is  mechanically  detached  in 
smaller  or  larger  fragments.  In  primary  tuberculosis  of  tlie  synovial 
membrane  the  process  usualh'  commences  at  the  periphery'  of  the 
articular  cartilage,  and  from  here  the  granulations  dip  down  into  the 
vascular  bone,  and  often  undermine  the  cartilage  extensively  before  any 
destructive  changes  are  witnessed  on  the  side  directed  toward  tlie  joint. 
In  such  cases  the  cartilage  is  not  only  often  extensively  detached,  but 
perforated  at  numerous  points  bj'  the  granulations  underneath  it.  The 
action  of  the  granulations  on  the  articular  extremities  of  the  bone 
produces  a  condition  which  has  been  described  for  centuries  as  caries. 
Caries  is  not  a  disease,  but  the  result  of  a  disease.  The  bone  becomes 
softened,  and  by  molecular  disintegration,  caused  by  action  of  the 
granulations,  it  becomes  porous  and  honey-combed.  Numerous  miliary 
nodules  can  be  seen  in  the  affected  area,  which,  in  the  course  of  time, 
imdergo  coagulation  necrosis  and  caseation.  In  long-standing  cases  the 
destruction  of  bone  is  so  extensive  that  in  the  hip-joint,  for  instance,  it 
may  result  in  the  loss  of  the  entire  head  of  the  femur  and  perforation 
of  the  acetabulum. 

Symptoms  and  Diagnosis. — The  s5'mptoms  var^-  according  to  the 
type  of  the  disease  and  manner  of  infection.  With  the  exception  of 
circumscribed  points  of  tenderness  outside  of  the  region  of  the  joint 
that  indicate  the  existence  of  primar}"  osteo-tuberculosis,  we  haA^e  no 
s^-mptoms  which  enable  us  to  make  a  positive  diagnosis  between  a 
primary-  osteal  and  a  primary  synovial  tuberculosis  of  a  joint.  The 
primary  osteal  form  is  the  most  common.  In  the  knee  the  proportion 
of  the  primary  osteal  to  the  primar}'  sj-novial  form  is  in  the  proportion 
of  3  to  1  ;  in  the  hip,  4  to  1 ;  in  the  elbow,  4  to  1.  As  to  age,  the  propor- 
tion is,  in  children  below  15  years  of  age,  2  to  1 ;  above  15,  3  to  1.  In  refer- 
ence to  the  location  of  the  joints  affected,  it  can  be  said  that  joint  tuber- 
culosis is  much  more  frequent  in  the  lower  than  in  the  upper  extremities. 
According  to  Albrecht,  out  of  325  cases,  in  91  the  disease  affected  the 
joints  of  the  upper,  and  in  234  those  of  the  lower,  extremities. 

I.  Swelling. — In  the  atrophic  form  of  plastic  s^'novitis,  the  caries 
sicca  of  Yolkmann,  so  common  in  the  shoulder-joint,  there  is  not  only 


512  PRINCIPLES    OF    SURGERY. 

no  swelling,  but  the  region  of  the  joint  may  even  be  found  atrophied 
from  muscular  atroph3^  The  absence  of  swelling  and  the  presence  of 
considerable  mobilit}'  in  the  joint  ma}'  lead  to  a  wrong  diagnosis  under 
the  impression  that  the  affection  is  a  neurosis.  A  careful  examination 
under  the  influence  of  an  anjBsthetic  will,  however,  reveal  restriction  of 
mobility  from  cicatricial  contraction  of  the  tubercular  capsule,  which 
will  enable  the  surgeon  to  make  an  early  and  correct  diagnosis.  The 
swelling  resulting  from  tubercular  hydrops  and  abscess  is  caused  exclu- 
sively by  distention  of  the  capsule  with  fluid,  as  the  capsule  in  either 
case  is  but  little  thickened  and  the  granulations  are  scanty.  In  both  of 
these  conditions  the  capsule  of  the  joint  is  often  enormously'  distended. 
In  the  knee-joint  the  patella  is  raised  from  the  condyles  of  the  femur, 
and  the  depression  on  each  side  of  it,  present  in  a  normal  condition  in 
the  extended  position  of  the  liml),  is  not  only  effaced,  but  replaced  b^^  a 
well-marked  prominence.  Fluctuation  is  distinct.  In  the  dry,  fungous 
variety  of  sj-novitis  the  swelling  is  due  to  the  masses  of  granulation 
tissue  Avithin,  and,  after  perforation  of  the  capsule  lias  occurred,  within 
and  outside  of  the  joint.  This  is  the  most  common  of  all  the  forms  of 
articular  tuberculosis.  The  old  authors  were  of  the  opinion  that  the 
oedema  in  the  neighborhood  of  a  white  swelling  was  due  to  expansion  or 
enlargement  of  the  articular  extremities  of  the  bones,  until  Samuel 
Cooper  pointed  out  that  it  was  caused  by  thickening  of  the  capsule. 
The  granulation  tissue  is  often  present  in  such  abundance  as  to  give  rise 
to  considerable  distention  of  the  joint,  and,  in  the  knee-joint,  elevating 
the  patella  from  the  condyles  of  the  femur  to  such  an  extent  that  the 
contour  of  the  joint  simulates  an  effusion  into  that  articulation.  The 
granulations  are  so  soft  that  on  palpation  in  these  cases  fluctuation  can 
be  distinctl}^  felt,  especiall}'  if  the  capsule  of  the  joint  is  very  thin  from 
overdistention  or  destructive  changes.  To  ascertain  the  character  of 
the  contents  of  such  a  joint,  it  is  usually  necessary  to  resort  to  an  ex- 
ploratory pinictnre.  The  invasion  of  the  para-articular  tissues  causes 
considerable  swelling  in  the  region  of  the  joint,  imparting  to  the  latter 
the  characteristic  spindle  shape  so  frequently  found  in  the  knee-,  elbow-, 
and  ankle-joint,  the  swelling  being  so  much  the  more  conspicuous  when 
atrophy  of  the  muscles  above  and  below  has  taken  place.  Extension  of 
the  infiltration  from  the  para-articular  tissues  in  the  direction  of  the 
subcutaneous  tissues  finall}^  causes  the  swollen  joint  to  be  covered  with 
a  whitish,  immovable,  dense  skin,  giving  the  joint  the  appearance  from 
which  the  time-honored  name  of  white  sivelling  was  derived.  If  a  peri- 
articular abscess  appear  tlie  swelling  of  the  joint  is  generally  diminished, 
while  a  new  swelling  forms  in  the  vicinity  or  some  distance  from  the 
joint. 


TUBERCULOSIS    OF   JOINTS.  513 

2.  Pain. — Pain,  as  a  s3'raptom  accompan^-ing  tuberculosis  of  joints, 
altliougli  always  present,  is  of  extremely  variable  intensity'.  In  some 
cases  it  is  so  sliglit  that  patients  will  continue  to  use  joints  distended 
with  masses  of  fungous  granulations  without  much  suffering,  while  in 
other  instances  a  limited  disease  in  the  joint  will  cause  complete  dis- 
ability^ and  a  great  deal  of  suffering.  According  to  ni}^  observation,  the 
pain  is  usually  more  severe  in  cases  where  the  granulations  are  scanty 
than  when  the  synovial  membrane  is  the  seat  of  extensive  fungosities. 
As  a  point  in  ditlerential  diagnosis,  it  may  be  said  that  in  osteal  tuber- 
culosis pain  is  present  from  the  beginning  in  the  bone,  and  is  not  much 
aggravated  In'  the  joint  disease  ;  while  an  almost  painless  primar}'  syno- 
vial tuberculosis  is  attended  b}'  severe  pain,  with  nocturnal  exacerbations 
as  soon  as  the  S3'novial  membrane  and  articular  cartilages  have  been  de- 
stroj'ed  and  the  bone  has  been  secondarily  implicated  in  the  inflamma- 
tory process.  Absence  of  tenderness  awa}'  from  the  joint  and  its  pres- 
ence in  the  line  of  the  joint  would  indicate  rather  a  primary  tuberculosis 
than  the  osteal  variet}'.  In  primary  synovial  tuberculosis  in  the  hip- 
joint  the  pain  is  located  in  the  joint  and  the  groin  ;  while  in  the  osteal 
form,  during  the  early  stage  at  least,  it  is  usuall}^  referred  to  the  inner 
aspect  of  the  knee. 

3.  Deformity. — Contraction,  lateral  deviations,  subluxations,  and 
other  abnormal  positions  usuall}'  indicate  more  or  less  destruction  of  the 
articular  surfaces  of  the  bones  and  lateral  ligaments.  These  malposi- 
tions are  not  seen  in  articular  tubercular  hj'drops  or  the  milder  forms  of 
synovial  tuberculosis,  while  we  find  different  degrees  of  one  or  more  of 
them  nearl}'  in  every  case  of  advanced  fungous  synovitis.  In  advanced 
cases  of  synovial  tuberculosis  of  the  knee-joint  the  joint  is  flexed,  the 
leg  rotated  outward,  and  the  head  of  the  tibia  displaced  backward.  In 
the  hip-joint  the  disease  gives  rise  to  flexion  of  the  thigh  upon  the  pelvis, 
and  first  eversion,  but  later  inversion,  of  the  limb.  After  separation  of 
the  head  of  the  femur,  or  extensive  destruction  of  the  articular  end  of 
this  bone  and  the  acetabulum,  the  contour  of  the  region  of  the  hip-joint 
and  the  position  of  the  limb  simulate  dislocation  of  the  head  of  the  femur 
upon  the  dorsum  of  the  ileum.  Tubercular  disease  of  the  elbow-joint 
gives  rise  to  flexion  and  pronation  of  the  forearm.  The  clinical  impor- 
tance of  au}'  of  these  displacements  lies  in  the  fact  that  the}'  signifv  a 
certain  amount  of  destruction  of  the  joint  structures,  thus  often  indi- 
cating surgical  interference  for  the  correction  of  the  deformity,  as  well 
as  the  removal  of  the  diseased  tissue.  Remembering  the  frequency'  of 
tubercular  affections  of  joints,  as  a  rule,  there  is  little  difficulty  in  their 
recognition,  if  the  historj-,  course,  and  S3'mptoms  are  carefull}'  studied 
and   analyzed.     Konig  justly  remarks  that  it  is  well  to  remember  that 


514  PRINCIPLES   OF    SURGERY. 

articular  tuberculosis,  even  if  the  disease  affect  a  large  joint,  is  practi- 
cally a  local  disease,  and  has  for  a  long  time  little  or  no  influence  on  the 
general  health  of  the  patient.  Thus,  we  may  find  patients  presenting  all 
the  appearances  of  robust  health  suffering  from  articular  tuberculosis. 
The  tubercular  articular  hydrops  is  distinguished  from  a  catarrhal  or 
rheumatic  synovitis  with  copious  effusion  b^-  its  persistency  and  tendency 
to  return  after  aspiration  or  after  active  use  of  the  joint.  The  presence 
of  flocculi  or  rice-bodies  in  a  joint  confirm  the  tubercular  nature  of  the 
affection.  A  tuberous  S3'novitis,  witli  the  formation  of  a  single  mass  of 
fibrous  tissue,  sessile  or  pedunculated,  might  l)e  mistaken  for  lipoma 
arborescens  or  gummata.  The  diagnosis  of  the  latter  will  be  cleared  up 
b}'  a  course  of  antisyphilitic  treatment,  which  should  alwaj's  be  insti- 
tuted in  cases  of  doubt.  Tubei'cular  joint  abscess  is  distinguished  from 
suppurative,  gonorrlioeal,  or  rheumatic  synovitis  b}'  the  pain  being  less 
and  the  absence  of  all  signs  of  acute  inflammation.  The  local  condi- 
tions in  fungous  synovitis  are  so  characteristic  that  they  can  hardly  be 
misinterpreted  by  a  careful  observer.  The  presence  or  absence  of  fluid 
in  the  joint  has  often  to  be  determined  by  an  exploratory  puncture.  The 
caries  sicca  of  Yolkmann,  or  dry,  pannous,  h3'perplastic  sjniovitis  of 
Hueter,  especially  as  found  in  the  shoulder-joint,  might  be  mistaken  for 
a  neurosis,  with  atrophy  of  the  muscles  covering  the  joint.  The  differ- 
ential diagnosis  can  be  made  b}'  making  the  examination  while  the 
patient  is  fully  imder  the  influence  of  an  anaesthetic.  If  the  affection  is 
a  neurosis,  motion  will  be  found  unimpaired  ;  if  it  is  tubercular,  the 
mobilit}'  of  the  joint  will  be  found  lessened  by  intra-articular  adhesions 
and  cicatricial  contraction  of  the  capsule  of  the  joint. 

Prognosis. — Tuberculosis  of  a  joint  may  terminate  in  a  spontaneous 
cure  in  cases  in  which  the  intensity  of  the  infection  is  slight,  or  the 
resistance  on  the  part  of  the  patient  is  so  great  that  the  fungous  granula- 
tions do  not  undergo  degenerative  changes,  but  are  converted  into 
connective  tissue.  A  partial  or  complete  S3mechia  of  the  cavity  of  a 
joint  is  often  one  of  the  unavoidable  results  in  such  cases,  leaving  the 
joint  in  a  permanently  stiff  condition.  This  endeavor  on  the  part  of  the 
organism  to  limit  tlie  extension  of  the  disease  is  often  observed  in  cases 
in  which  the  joint  affection  occurs  in  connection  with  osteal  tubercu- 
losis. As  soon  as  perforation  of  a  focus  into  a  joint  iias  occurred  a  wall 
of  granulation  tissue  is  tlirown  out  around  the  circumscribed  area  of 
infection,  and,  under  favorable  circumstances,  a  partition  of  cicatricial 
tissue  is  formed  which  isolates  the  infected  from  the  intact  portion  of 
the  joint.  In  such  instances  we  haA^e  an  illustration  hoAv  the  tubercular 
process  is  retarded,  and  sometimes  permanently'  arrested,  by  the  trans- 
formation of  granulation  into  connective  tissue.     For  such  a  favorable 


TUBERCULOSIS   OF   JOINTS.  515 

termination  to  take  place  it  is  necessary  that  the  tubercular  virus  should 
be  attenuated  by  age  or  want  of  a  proper  nutrient  medium,  or  that  the 
pathogenic  effect  of  the  bacilli  should  be  neutralized  b_y  an  adequate 
resistance  on  the  part  of  the  tissues  before  degenerative  changes  have 
occurred  in  the  granulation  tissue.  The  course  of  articular  tuberculosis 
is  so  variable  in  difterent  cases  that  it  is  impossible,  during  the  earlj' 
stages  of  an  attack,  to  predict  anythiug  certain  iu  reference  to  the 
probable  outcome.  A  spoutaneous  cure  is  more  likely  to  take  place  if 
the  patient  is  joung,  not  aujemic,  and,  at  the  same  time,  well  nourished. 
The  hj^gienic  surroundings  must  also  be  taken  into  consideration  in 
rendering  a  prognosis.  The  disease  shows  greater  tendencies  to  limita- 
tion in  children  than  in  persons  past  the  age  of  puberty. 

Amoug  the  differeut  forms  of  joint  tuberculosis  the  tubercular 
hj'drops  and  caries  sicca  are  the  most  benign,  and  in  these  cases  a  spon- 
taneous cure  is  most  frequentl}'  renlized  and  the  same  conditions  are 
effected,  and  which  are  also  amenable  to  successful  surgical  treatment. 
The  caries  sicca  ma}',  according  to  Kdnig,  terminate  in  a  spontaneous 
cure  in  two  or  three  j-ears,  with  some  loss  of  motion  in  the  joint.  It  is 
sometimes  difficult  to  ascertain  in  a  given  case  when  the  lesion  can  be 
considered  as  cured.  As  the  most  reliable  evideuces  that  such  favorable 
termination  has  taken  place  must  be  considered  disappearance  of  swell- 
ing, pain,  tenderness,  and  restoration  of  function  as  far  ns  this  can  be 
expected.  The  patient  should  not  be  permitted  to  use  the  limb  until  the 
active  symptoms  of  inflammation  have  disappeared.  The  danger  to  life 
arises  from  the  existence  of  complications,  foremost  among  them  being 
septic  infection,  pulmonary  or  general  tuberculosis,  and  amyloid  degen- 
eration of  im})ortant  internal  organs.  Septic  infection  is  caused  either 
hy  localization  of  pus-microbes  brought  to  the  tubercular  focus  through 
the  circulating  blood,  or,  what  is  more  frequently  the  case,  through  an 
infection-atrium,  created  by  a  spontaneous  opening  through  an  operation 
wound,  or,  finall}',  through  a  fistulous  communication  with  the  joint. 
Many  neglected  cases  of  joint  tuberculosis  die  annuiilly  of  pulmonary  or 
general  tuberculosis.  Billroth  states  that  in  sixteen  j-ears  27  per  cent, 
of  bone  and  joint  tuberculosis  were  lost  in  this  ^vay.  Konig,  from  a 
table  of  in  operations  for  tuberculosis,  found  that  after  four  years  16 
per  cent,  had  died  from  general  tuberculosis.  If  a  patient  escape  death 
from  septic  infection,  after  secondary  infection  with  pus-microbes,  he  is 
liable  to  succumb  several  years  later  to  amyloid  degeneration  of  the 
spleen,  the  liver,  and  especially'  the  kidneys,  with  its  accompanying 
anasarca. 

Treatment. — As  spontaneous  cure  in  cases  of  joint  tuberculosis  is 
more  frequently  the  exception  than  the  rule,  and  if  finally'  it  does  take 


516  PRINCIPLES   OF    SURGERY. 

place  it  does  so  generally  after  the  limb  has  become  so  much  deformed 
that  it  has  become  useless  and  will  require  a  formidable  operation  to 
restore  partial  function,  it  is  evident  that  timelj-  surgical  treatment 
should  be  adopted  to  eradicate  the  disease,  preserve  function,  and,  at  the 
same  time,  protect  the  patient  as  far  as  can  be  done  against  general 
infection. 

I.  Rest. — As  in  cases  of  osteo-tuberculosis,  rest  is  an  important  ele- 
ment in  the  treatment  of  tubercular  joints.  It  is  even  more  important  to 
secure  rest  for  an  inflamed  joint  than  for  an  inflamed  bone,  as  the  inflam- 
mation is  alwa3's  greati}'  aggravated  b}'  the  movements  in  the  joint  that 
necessaril}'  take  place  as  long  as  the  joint  is  used,  which  does  not  appl}' 
with  equal  force  to  cases  of  osteo-tuberculosis.  The  best  method  to  fulfill 
this  indication  is  to  immobilize  the  limb  in  a  plaster-of-Paris  splint, 
"which  does  not  necessarily  confine  the  patient  to  his  room  or  bed.  If 
one  of  the  lower  extremities  is  to  be  encased  in  a  plaster  splint,  I  am 
in  the  habit  of  applying  the  plaster-of-Paris  roller  over  tight-fitting  knit 
drawers,  which  protect  the  skin  much  better  than  an  ordinary  roller 
bandage.  All  bony  prominences  should  be  protected  against  pressure 
b}'  careful  padding  with  absorbent  cotton.  If  the  hip-joint  is  the  seat 
of  inflammation  the  splint  is  applied  with  the  limb  in  the  extended  posi- 
tion, while  the  patient  stands  on  the  sound  limb  upon  a  low  stool,  as  in 
this  position  autoextension  is  made  by  the  weight  of  the  suspended  limb. 
In  such  cases  the  splint  must  extend  from  the  toes  and  embrace  the 
entire  limb,  the  whole  pelvis,  and  abdomen  as  far  as  the  umbilicus,  and 
the  opposite  limb  as  far  as  the  knee-joint.  In  tuberculosis  of  the  knee- 
joint  the  s[)lint  should  extend  from  the  toes  to  the  groin,  and,  in  ankle- 
joint  affections,  from  the  toes  to  the  knee-joint.  Immobilization  is  to  be 
made  with  the  limb  in  such  a  position  that  in  case  the  joint  should  be- 
come permanently  stiff  the  limb  can  l)e  used  to  greatest  advantage.  A 
slight  degree  of  flexion  in  the  hip-  and  knee-  joint  is  to  be  preferred  to 
a  perfectly  straight  position.  In  inflammation  of  the  shoulder-joint  the 
limb  makes  the  necessary  counter  extension  and  fixation  of  the  joint  by 
confining  the  limb,  with  the  forearm  flexed,  at  right  angles  to  the  side 
of  the  chest,  bj'  strips  of  adhesive  plaster  or  a  plaster-of-Paris  bandage. 
The  hand  should  be  slightl}^  extended  in  immobilizing  the  forearm  in  the 
treatment  of  tuberculosis  of  the  Avrist,  Avhile  the  forearm  is  flexed  at  a 
right  angle  to  the  arm  in  tubercular  synovitis  of  the  elbow-joint,  with  the 
band  in  position  half-waj'  between  pronation  and  supination.  Early  im- 
mobilization of  a  tubercular  joint  not  only  secures  absobite  rest  for  the 
joint,  but,  at  the  same  time,  this  treatment  i)revents  to  a  great  extent 
subsequent  deformities.  Treatment  by  immobilization  should  be  con- 
tinued until  all  symptoms  of  inflammation  have  subsided,  or  until  more 


TUBERCULOSIS    OF    JOINTS.  517 

radical  measures  become  necessary.  If  the  arthritis  has  already'  resulted 
in  contractures  the  treatment  by  extension  with  weight  and  pulley  is  in 
place,  and  should  be  continued  until  the  limb  has  been  brought  in  proper 
position  for  treatment  b^'  immobilization. 

2.  Aspiration. — In  tubercular  hydrops  the  intra-articular  effusion  is 
often  ver}-  copious,  resulting  in  enormous  distention  of  the  capsule  of 
the  joint,  which,  if  continued  for  an3'  length  of  time,  must  necessaril}' 
result  in  great  weakening  of  the  joint.  Aspiration  under  these  circum- 
stances relieves  the  distention  and  places  the  vessels  in  the  s^'novial 
membrane  in  a  better  condition  to  perform  their  function  in  the  subse- 
quent removal  of  the  inflammatory  product  b}'  absorption.  After  evacua- 
tion of  the  contents  of  the  joint  the  limb  should  be  immobilized  and 
rapid  re-accumulation  of  the  fluid  prevented  by  uniform,  equable  com- 
pression of  the  joint  by  strijis  of  adhesive  plaster  or  rubber  bandnge. 

3.  Subcutaneous  Evacuation  of  Contents  of  Joint,  followed  by 
lodoformization. — In  tubercular  hydrops  and  abscess  of  a  joint,  subcu- 
taneous evacuation  of  the  fluid  contents,  followed  by  iodoformization 
practiced  in  the  same  manner  as  has  been  described  in  the  treatment  ol' 
tubercular  abscess,  yields  much  more  satisfactory  results  than  simple 
aspiration.  In  tubercular  hj'drops  irrigation  of  the  joint  with  a  3-per- 
cent, solution  of  boric  acid  is  onl}-  necessary  for  the  removal  of  rice- 
bodies  ;  if  such  are  not  present,  the  iodoform  mixture  maj-  be  injected 
at  once.  Tubercular  abscess  always  requires  a  preliminary  irrigation 
with  some  mild  antiseptic  solution,  for  the  purpose  of  removing  detached 
and  disintegrated  tubercular  products  before  the  iodoform  mixture  is 
injected.  Krause,  in  the  last  eighteen  months,  treated  43  tuljercular 
joints  by  means  of  iodoform  injections;  cases  were  treated  by  other 
means,  and  where  cure  without  operation  seemed  imi)ossible,  but  in 
wiiich  fistulse  were  not  yet  formed.  The  injections  were  repeated  at 
intervals  of  two  or  three  weeks.  Pain  was  greatly  relieved  by  this 
treatment ;  the  swelling  j'ielded  much  more  slowly,  though  in  six  weeks 
some  cases  showed  a  reduction  in  size  and  a  hardness  of  the  affected 
parts.  The  abscess-cavities  frequentl}'  filled  again,  rapidl3'  at  first,  but 
ultimately  re-accumulation  ceased.  In  some  cases  fistulse  formed  at  the 
seat  of  puncture,  which  first  discharged  pus,  then  serum,  but  ultimately 
healed  entireh".  In  a  fair  percentage  treated  in  this  way  definitive  healing 
was  obtained.  This  treatment  promises  the  best  results  in  cases  where 
granulation  tissue  is  scant}',  and  where  the  inflammatorj'  product  has  not 
undergone  extensive  caseation.  Its  utilit}'  is  much  impaired  if  suppu- 
ration has  taken  place  in  the  joint.  Billroth  opens  the  joint,  evacuates 
its  contents  through  the  incision,  removes  (if  present)  tubercular 
sequestra,  rice-bodies,  and  tubercular  meml)ranes,  and  then  treats  the 


518  PRINCIPLES   OF   SURGERY. 

joint  by  iodoforniization.  In  general  practice,  however,  it  is  much 
safer  to  follow  tlie  subcutaneous  method  by  puncturing  the  joint  with  a 
medium-sized  trocar,  using  the  canula  for  evacuation,  irrigation,  and 
iodoformization. 

4.  Arthrectomy. — Excision  of  the  infected  tissues  in  primary  tuber- 
culosis of  the  synovial  membrane  has  been  practiced  for  a  number  of 
3'ears,  and  the  results  of  this  treatment  have  been  quite  encouraging. 
Primary  synovial  tuberculosis,  without  any  foci  in  the  articular  ends  of 
the  bones,  should  be  treated  by  arthrectomy  and  not  by  resection,  as  by 
the  former  operation  the  diseased  tissues  can  be  removed  effectually 
without  unnecessary  loss  of  healthy  tissues  that  are  sacrificed  b}'  the  latter 
operation.  The  success  of  an  operation  for  tubercular  affections  depends 
largely  upon  the  thoroughness  with  which  the  operation  is  done  and  the 
absence  of  suppuration.  Arthrectomy  should  be  performed  before 
fistulous  openings  have  formed,  and  the  joint  must  be  opened  by  an 
incision  that  will  expose  every  nook  and  corner  of  the  capsule.  Of  the 
many  incisions  that  have  been  devised  for  opening  the  knee-joint,  the 
one  I  shall  describe  here  offers  the  greatest  advantages  and  is  open  to 
the  least  objections.  The  old-fashioned  horseshoe  incision,  with  the 
convexity  directed  downward,  makes  it  very  difficult  to  suture  the  wound, 
and  leaves  a  scar  where  it  is  most  exposed  to  injur3%  The  incision 
carried  directly  across  the  knee-joint,  if  the  patella  is  divided  at  the  same 
time,  leaves,  subsequentl}',  the  superficial  and  deep  parts  of  the  wound 
directly  opposite;  if  the  patella  is  preserved,  the  scar  of  the  external 
incision  falls  upon  the  most  prominent  part  of  the  patella,  which  is  again 
a  great  disadvantage.  The  incision,  which  for  several  3'ears  I  have 
alwa3's  selected  in  opening  the  knee-joint  in  performing  arthrectomy  or 
resection,  is  slightl3'  curved,  but  with  the  convexity  directed  upward. 
It  is  carried  from  the  most  dependent  portion  of  the  knee-joint,  at  a 
point  corresponding  to  the  most  prominent  part  of  the  internal  condyle 
of  the  femur,  in  a  gentle  curve  to  the  upper  border  of  the  patella,  and 
from  here  downward  and  outward  to  a  point  opposite  Avliere  it  was  com- 
menced. The  short,  semilunar,  cutaneous  flap  is  now  detached  and 
turned  downward.  After  this  an  incision  is  carried  directh' 'across  the 
joint,  dividing  the  lateral  ligaments  and  crossing  the  patella  transversely 
at  its  centre.  The  patella,  at  this  step  of  tlie  operation,  is  divided  with 
a  saw.  The  upper  recesses  of  the  synovial  sac  are  freely  opened  b3' 
making  an  incision  on  each  side  of  the  upper  half  of  the  patella,  which 
is  carried  as  far  as  the  upper  recess  of  the  S3'novial  sac.  The  rectangular 
flap,  composed  of  the  upper  end  of  the  patella  with  its  muscular  attach- 
ments, is  reflected,  which  exposes  ever3'  portion  of  the  upper  part  of  the 
sj'novial  recess.     A  somewhat  similar  flap  is  made  of  the  lower  half  of 


TUBEKCUL06IS    OF    JOINTS.  519 

the  patella  and  its  tendon,  reflected  in  a  downward  direction,  b}-  which 
the  tissues  underneath  that  portion  of  tlie  patella  and  its  ligament  are 
fully  exposed.  Witli  the  knee-joint  thus  exposed  it  is  not  diflicult  to 
extirpate,  with  the  help  of  a  catch-forceps,  a  siiai-p  scalpel,  and  a  pair  of 
curved  scissors,  the  entire  capsule.  The  part  of  the  capsule  that  will  be 
found  most  difficult  to  remove  is  that  portion  which  covers  the  popliteal 
vessels,  and  dips  down  behind  the  condyles  of  the  femur  and  behind  the 
tuberosities  of  the  tibia.  During  this  part  of  the  operation  the  leg  must 
be  forcibly  flexed  over  a  small  cushion,  or  the  fist  of  an  assistant,  in  the 
popliteal  space.  Arthrectomy  is  always  a  tedious  operation,  as  it  is 
absolutely  necessary-  to  remove  all  of  the  infected  tissues  in  order  to 
secure  permanent  success.  If  the  patella  is  not  diseased  it  should  never 
be  removed.  After  the  capsule  has  been  extirpated  the  patella  is  united 
by  two  chromicized  catgut  sutures,  I  have  never  failed  in  obtaining 
bony  union  in  four  to  six  weeks  after  this  method  of  coaptation.  After 
extirpation  of  the  capsule,  and  before  the  elastic  constrictor  is  removed, 
the  whole  surface  should  be  once  more  irrigated  with  a  hot  solution  of 
corrosive  sublimate  (1  to  1000),  after  which  it  is  rubbed  off"  with  dry 
iodoform  gauze,  in  order  to  remove  any  detached  fragments  that  have 
not  been  washed  away.  The  whole  surfece  is  now  freely  sprinkled  with 
impalpable  iodoform,  which  is  rubbed  into  the  surface.  Before  the  con- 
strictor is  removed  the  wound  is  packed  witli  aseptic  gauze,  the  flaps  are 
hiid  over  it,  and  manual  compression  made  for  five  to  ten  minutes  after 
the  removal  of  the  constrictor,  with  the  limb  in  an  elevated  position. 
This  simple  procedure  serves  an  admirable  purpose  in  controlling  capil- 
lary haemorrhage,  and  reduces  the  necessit}'  of  recourse  to  ligature  to  a 
minimum. 

After  all  the  bleeding  has  been  arrested,  the  patella  is  sutured,  and 
the  deep  parts  of  the  wound  are  united  b}'  buried  sutures.  Tubuhir  ilrain- 
age  can  usually  be  dispensed  with,  as  a  capillary  drain  composed  of  a  few 
threads  of  catgut  will  answer  an  excellent  purpose, and  will  not,  like  the 
tubular  drain,  necessitate  an  early  change  of  dressing.  The  external  in- 
cision is  closed  with  silk  sutures,  the  line  of  suturing  being  out  of  the  way 
of  the  patella,  the  parts  united  with  the  buried  sutures  being  covered 
throughout  by  the  external  flap.  A  careful  hoemostasis  and  rigid  anti- 
septic precautions  will  make  it  unnecessary  to  change  the  dressing  earlier 
than  the  end  of  the  second  week,  and  on  this  account  I  prefer  to  immo- 
bilize the  limb  in  a  plaster-of-Paris  splint  applied  over  a  copious  antiseptic 
dressing.  The  limb  must  be  kept  in  an  elevated  position  for  at  least  six 
hours  after  the  operation,  so  as  to  diminish  the  amount  of  parenchj^ma- 
tous  haemorrhage.  If  all  the  infected  tissues  have  been  removed  and  the 
wound  remains  in  an  aseptic  condition,  the  external  wound  will  be  found 


520  PRINCIPLES    OF    SURGERY. 

closed  in  the  course  of  two  or  three  weeks.  A  fair  restoration  of  func- 
tion with  partial  mobility  of  the  joint  can  be  expected  in  favorable  cases. 
Passive  motion  must  be  delayed  until  the  patella  has  firmly  united,  which 
will  require  from  three  to  four  weeks  in  children  and  nearly  twice  this 
length  of  time  in  adults.  After  the  patella  has  united  and  the  external 
wound  is  completely  healed,  recovery  is  hastened  by  passive  motion, 
massage,  and  use  of  the  faradic  current.  Arthrectoni}'  has  a  future  in  the 
treatment  of  primary  synovial  tuberculosis  of  the  knee-joint,  but  for  well- 
known  anatomical  reasons  it  is  not  equally  applicable  in  the  treatment 
of  synovial  tuberculosis  of  any  otlier  of  the  larger  joints.  It  is  possible 
that  the  operation  will  be  modified  and  sufficiently  perfected  in  the 
future  so  as  to  be  applicable  in  the  treatment  of  synovial  tuberculosis 
of  the  hip-  and  shoulder-  joint.  In  2  cases  of  tuberculosis  of  the 
elbow-joint  I  obtained  an  excellent  result  from  arthrectomy  combined 
with  temp()rar3^  resection  of  the  olecranon  process.  This  process  was 
divided  obliquely  with  a  saw  at  its  junction  with  the  shaft  of  the  ulna, 
and,  after  the  extirpation  of  all  of  the  infected  soft  tissues  of  tlie  joint, 
the  process  was  fastened  in  its  proper  place  witli  an  aseptic  ivory  nail. 
The  functional  result  was  satisfactor3^ 

5.  Atypical  Resection. — The  incision  in  atypical  and  typical  resec- 
tion of  the  knee-joint  should  be  the  same  as  has  been  described  above. 
The  patella  is  divided  transversel_y,  and,  if  it  does  not  contain  a  tuber- 
cular focus,  it  is  not  necessary  or  advisa])le  to  remove  it,  as  its  conti- 
nuity, after  resection,  can  be  restored  by  suturing  with  a  durable  form 
of  catgut.  An  at^-pical  resection  consists  in  the  removal  of  tubercular 
foci  in  the  epiphyseal  extremities  of  the  bones  that  enter  into  the  forma- 
tion of  the  joint,  without  removing  the  entire  articular  extremities  by 
a  transverse  section  with  the  saw.  The  unnecessarj-  removal  of  the 
epiphyseal  extremities  should  especially  be  avoided  in  the  case  of  chil- 
dren, as  the  removal  of  one  or  both  centres  of  growth  of  bone  will 
result  in  so  much  shortening  of  the  limb  subsequenth^  as  often  to  render 
it  not  onl}^  perfectly  useless,  but  it  becomes  a  burdensome  appendage. 
In  children  atypical  resection  should  be  practiced  in  all  cases  where  all 
the  foci  in  the  articular  extremities  can  be  reached  and  removed  b}^  this 
method.  The  proper  instruments  to  be  used  in  this  operation  are  the 
chisel,  bone-forceps,  and  sharp  spoon.  After  the  joint  has  been  freely 
opened,  the  articular  surfaces  are  carefully  inspected  for  evidences  of 
deeply-seated  foci.  If  perforation  into  the  joint  has  taken  place,  the 
cavit}-  is  free)}'  exposed  from  the  articular  surface,  and  all  of  the  infected 
tissues  are  removed  with  chisel  and  sharp  spoon.  It  is  important  not 
onlj'^  to  remove  necrosed  bone,  granulation  tissue,  and  caseous  material, 
but  also  the  surrounding  osteoporotic  zone  of  bone  that  possibly  might 


TUBERCULOSIS    OF    JOINTS.  521 

contain  tubercle  bacilli.  A  deep-seated  focus  may  be  suspected  and 
searched  for  if  the  articular  cartilage  has  become  detached  over  a  gretiter 
or  less  extent.  Explorations  with  a  small  perforator  can  be  made  in 
different  directions  from  the  articular  surface  in  searching  for  deeply- 
seated  foci.  If  the  articular  cartilage  has  become  detached  over  a  con- 
siderable area  by  granulations  underneath  it,  it  should  be  removed,  and 
the  exposed  bone  must  be  subjected  to  another  careful  examination  for 
the  purpose  of  locating  and  treating  deepl}'  seated  foci.  A  circumscribed 
area  of  great  vascularit}'  is  a  suspicious  indication,  and  calls  for  a  lim- 
ited excavation  with  a  small,  sharp  spoon  for  diagnostic  purposes.  It 
is  well  for  the  surgeon  to  remember  that  primary  osteo-tuberculosis  with 
secondary  involvement  of  a  joint  usually  consists  of  more  than  one 
focus  in  one  or  both  epiphyseal  extremities.  A  tubercular  infarct  is 
generally  recognized  b3'  examining  the  articular  surface,  as  the  cartilage 
or  the  exposed  portion  of  the  wedge-shaped  sequestrum  presents  ap- 
pearances of  necrosis  that  cannot  be  mistaken.  After  the  extraction  of 
the  sequestrum  the  tubercular  cavity-  is  submitted  to  the  same  treatment 
as  when  dealing  with  a  granulating  or  caseous  focus.  In  primary'  syno- 
vial tuberculosis,  with  extension  of  the  disease  to  the  subjacent  bone,  it 
becomes  necessar}-  to  remove  the  honey -combed,  softened  bone  over  tlie 
entire  surface  with  the  sharp  spoon  and  chisel.  Before  the  operation  is 
extended  to  the  bone  in  osteo-tuberculosis,  it  is  always  necessary  first  to 
extirpate  with  knife  and  scissors  the  infected  soft  structures  of  the 
joint,  the  synovial  membrane  and  ligaments,  as  otherwise  the  healthy 
vascular  bone  may  become  an  infection-atrium  for  traumatic  infection, — 
a  not  ver}-  infrequent  and  serious  complication  after  oi)erations  on  bones 
and  joints  for  tuberculous  affections. 

Wartmann,  after  giving  a  careful  account  of  the  results  following- 
excision  of  tubercular  joints  in  the  hospital  practice  of  Feurer,  gives 
the  statistics  of  837  cases  of  excision  of  joints  for  tuberculosis  from  the 
practice  of  difTerent  operators.  Of  this  number  225  died.  Of  the  fatal 
cases,  in  26  death  followed  the  operations  closelj',  and  resulted  from 
acute  tuberculosis,  probably  induced  1)\-  the  operation.  Konig  observed 
16  cases  in  his  own  practice  in  which  miliary  tuberculosis  followed 
almost  immediately  after  operations  on  bones  and  joints  for  tubercular 
affections.  Konig  states  that  the  secondary  infection  sets  in  seven  to 
ten  days  after  operation,  which  may  have  lieen  perfectly  aseptic,  with 
healing  of  the  wound  by  primary  union.  The  secondarv  tubercular 
infection  appears  either  as  an  acute  pulmonar}-  tuberculosis  or  tuber- 
cular meningitis,  terminating  in  death  three  or  four  weeks  after  the 
operation.  It  is  not  difficult  to  conceive  the  modus  operandi  of  such 
an  occurrence.     The  resection  wound  opens  numerous  veins  in  the  bone, 


522  PRINCIPLES    OF    SURGERY. 

the  lumina  of  which  remain  patent,  ready  for  the  introduction  of  minute 
fragments  of  granulation  tissue  or  bacilli,  which,  on  entering  the  venous 
circulation,  are  the  direct  cause  of  metastatic  tuberculosis  in  distant 
organs.  We  must  take  it  for  granted  in  such  cases  that  a  tubercular 
focus,  during  the  operation,  furnished  the  essential  infected  fragments 
of  granulation  tissue,  or  free,  bacilli  are  aspirated  or  forced  into  the 
openings  of  wounded  vessels,  and  through  them  gain  entrance  into  the 
general  circulation.  To  guard  against  such  an  accident,  it  is  necessary 
to  remove  from  the  joint  all  possible  source  of  infection  before  operat- 
ing on  the  articular  extremities^  Cartilage  that  remains  firmly  attached 
to  the  bone  may  be  left.  After  all  foci  have  been  radically  eliminated, 
the  field  of  operation  is  flushed  with  an  antiseptic  solution,  and,  after 
drying  and  iodoformization,  the  bone-cavities  are  packed  with  decalcified 
antiseptic  bone-chips,  and  the  operation  is  completed  in  the  same  manner 
as  in  arthrectoni}'. 

The  treatment  of  bone-cavities  with  decalcified  bone-packing  is  of 
the  greatest  utilit}-  in  atypical  resection.  An  at3'pical  resection  with 
subsequent  implantation  of  decalcified  bone  has  for  its  objects  complete 
removal  of  the  infected  tissues  in  the  joint  and  the  surrounding  bone, 
and  the  partial  restoration  of  the  parts  destro^'ed  by  disease  or  removed 
during  the  operation.  In  at^-pical  resection  of  the  knee-joint  it  is  not 
uncommon  that  nearly  an  entire  condyle  of  the  femur  or  tuberosity  of 
the  tibia  must  be  removed.  In  such  cases  the  surgeon  aims  at  bony 
union  between  the  articular  ends  of  the  bones,  which  is  accomplished  in 
the  most  satisfactory  manner  by  placing  the  parts  in  a  condition  to 
repair  the  lost  bone-tissue,  which  ma3'  be  done  by  filling  the  defect  with 
decalcified  bone-chips.  I  have  repeatedly  made  excavations  in  one  of 
the  condyles  of  the  femur  and  in  the  head  of  the  tibia  from  the  joint 
surface,  the  size  of  a  small  orange,  and  obtained  bony  ankylosis,  with 
the  limb  in  a  good  position,  b3'  filling  the  cavities  with  bone-chips.  As 
the  bone-chips  are  always  iodoformized  before  implantation,  they  serve  a 
useful  purpose  not  only  b}'  furnishing  a  temporary  scaff"olding  for  the 
reparative  material,  but  they  constitute  a  valuable  therapeutic  measure 
in  the  prevention  of  a  local  recurrence  of  the  disease  in  case  tubercle 
bacilli  should  remain  in  the  cavity  or  its  immediate  vicinity.  Immobili- 
zation of  the  limb  after  resection  should  be  continued  until  the  process 
of  repair  has  been  completed,  which,  under  tlie  most  favorable  condi- 
tions, requires  from  six  weeks  to  two  months.  Atypical  resections  are 
applicable  onl}'  to  certain  joints,  as  the  knee-,  elbow-,  ankle-,  and  tarsal 
joint.  The  elbow-joint  is  most  accessible  throngh  a  long,  straight  in- 
cision, and  after  temporary  resection  of  the  olecranon  process.  At3'pical 
resection  of  the  ankle-joint  can  be  done  tlirough  two  lateral  incisions, 


TUBERCULOSIS    OF    JOINTS.  523 

with  chisel  and  sharp  spoon.  In  all  resections,  atypical  and  typical, 
ignipuncture  is  indicated  after  the  excision  has  been  completed,  if  any 
portion  of  the  bone  is  abnormally  osteoporotic,  as  this  procedure  will 
stimulate  the  process  of  repair,  and  may  prove  useful  in  destroying  in- 
fected tissues,  which,  from  their  macroscopical  appearance,  indicate  a 
heialthj'  condition. 

6.  Typical  Resection. — In  typical  resection  one  or  both  articular 
extremities  are  sawn  across  and  removed.  In  the  hip-joint  it  implies 
the  excision  of  the  head,  neck,  and  part  or  the  whole  of  the  greater 
trochanter  of  the  femur.  A  typical  resection  of  the  wrist-joint  means 
the  removal  of  the  entire  carpus,  with  or  without  the  articular  surfaces 
of  the  radius,  ulna,  and  metacarpal  bones.  In  a  typical  resection  of  the 
shoulder-joint  the  head  of  the  humerus  is  removed.  In  the  knee-joint 
the  operation  means  excision  of  the  articular  surfaces  of  the  femur  and 
tibia  ;  in  the  elbow-joint,  of  the  humerus,  radius,  and  ulna  ;  in  the  ankle,  of 
the  tibia,  fibula,  and  astragalus.  Typical  resections  are  alwaj-s  made  for 
tubercular  aftections  of  the  shoulder-,  hip-,  and  wrist- joint.  In  the  re- 
maining larger  joints  it  is  more  frequentl}'  resorted  to  in  adults  than 
children.  In  children  the  operation  is  limited,  with  tlie  exception  of  the 
shoulder-,  hip-,  and  wrist- joint,  to  cases  where  the  articular  extremities 
are  so  extensively'  diseased  that  an  atypical  resection  would  fail  in  re- 
moving all  of  the  infected  tissues.  Removal  of  the  diseased  synovial 
membrane  and  ligaments  should  precede  section  of  the  bones  with  the 
saw  wherever,  from  the  anatomical  construction  of  the  joint,  tliis  can  be 
done.  In  the  hip-  and  shoulder- joint  the  liead  of  the  bone  must  be  re- 
moved first  before  the  soft  structures  of  the  joint  can  be  removed.  The 
operation  best  adapted  for  resection  of  the  hip-joint  is  the  one  devised 
by  Koiiig,  b3"  w^iich  the  borders  of  the  trochanter  major  are  preserved. 
In  this  operation  the  section  of  the  bone  must  be  made  "with  a  chisel. 
Tlie  entire  neck  and  head  of  the  femur  are  removed  b}'  dividing  the 
bone  transversely  with  a  chisel  just  below  the  neck,  with  the  exception 
of  the  borders  of  the  greater  trochanter,  which  are  split  off  with  the 
same  instrument.  The  capsular  ligament  is  removed  as  thoroughly  as 
possible,  and  tlie  acetabulum  is  scraped  out  with  a  sharp  spoon.  Pro- 
A'ision  for  drainage  must  be  made  in  all  hip-joint  resections.  The  after- 
treatment  consists  of  rest  in  bed  upon  a  smooth  mattress,  with  the  limb 
extended  by  weight  and  pulley  in  an  abducted  position.  After  six  weeks 
the  patient  is  allowed  to  walk  on  crutches,  with  a  raised  sole  under  the 
shoe,  worn  on  the  opposite  side,  so  that  the  limb  on  the  resected  side 
makes  the  necessary  autoextension.  During  the  night  extension  is 
:ip[)lied  for  eight  mouths  or  a  year,  in  order  to  prevent  unnecessary 
shortening.     Eversion  and  inversion  of  the  limb  while  the  patient  is  in 


524  PRINCIPLES   OF    SURGERY. 

bed  are  prevented  either  by  a  Volkmaim  railway-splint  or  by  support- 
ing the  limb  with  sand-bags,  applied  to  each  side.  Immobilization, 
after  resection  of  the  shoulder-,  elbow-, wrist-,  knee-,  and  ankle-joint,  is 
best  secured  in  a  plaster-of-Paris  dressing,  which  also  serves  an  excellent 
purpose  in  keeping  the  antiseptic  dressing  in  situ. 

Temporary  resection  of  the  olecranon  process  in  resection  of  the 
elbow-joint  h;ts  yielded  excellent  results  in  my  hands,  as  by  it  the  inser- 
tion of  tlie  bieei)s  muscle  is  not  disturbed.  The  resected  olecranon,  after 
tlie  removal  of  an}'  foci  it  may  contain,  is  riveted  to  a  denuded  surface 
of  the  shaft  of  the  ulna  with  a  sterilized  ivory  or  bone  nail  after  the 
resection  has  been  completed.  The  forearm  is  immobilized  in  a  semi- 
flexed position  until  bone  union  between  the  ulna  and  olecranon  process 
has  taken  place,  which  usually  requires  about  six  weeks.  After  this  time 
passive  motion  and  massage  should  be  made  to  increase  the  mobilit}'  of 
the  joint.  A  straight,  single  incision  upon  the  dorsal  side  is  best 
adapted  for  resection  of  the  wrist-joint,  as  the  extensor  tendons  of  the 
hand  and  fingers  can  be  drawn  aside  sufficiently  to  afford  ample  room  for 
the  removal  of  the  entire  carpus.  In  the  after-treatment  of  excision  of 
the  wrist  the  forearm  and  hand  as  far  as  the  metacarpo-phalangeal  joints 
are  encased  in  a  plaster-of-Paris  splint,  with  the  hand  in  a  slightly- 
extended  position.  Immediate  fixation  of  the  resected  ends  by  means 
of  bone  or  ivory  nails,  after  excision  of  the  knee,  is  superfluous,  as  the 
parts  can  be  kept  in  accurate  position  by  ordinar}'  fixation  dressing.  In 
knee-joint  resections  the  section  through  the  bones  must  be  made  in  such 
a  manner  that  when  the  sawn  surfaces  are  brought  in  apposition  the  leg 
will  be  slightly  flexed,  as  this  position  enables  the  patient  to  walk  more 
gracefuU}'  than  with  a  straight,  stiff"  limb.  The  artificial  support  must 
not  be  removed  until  firm  bony  union  has  taken  place,  which  will  require 
from  two  to  three  months,  according  to  patient's  general  health  and  age. 

7.  Amputation. — -Amputation  must  be  reserved  for  cases  presenting 
special  indications.  It  is  the  onl}'  operation  that  promises  any  benefit 
if  the  patient  suffer  from  tuberculosis  of  other  organs,  -provided  the 
general  conditions  furnish  no  positive  indications.  It  is  also  indicated 
if  a  tubercular  abscess  has  perforated  the  capsule  of  a  joint  and  has 
extensively  infiltrated  the  surrounding  tissues.  This  condition  is  to  be 
expected  if  the  limb  has  become  oedematous  some  distance  from  the 
joint.  Tlie  flaps  must  be  taken  from  the  side  of  the  limb  where  the  skin 
is  in  the  best  condition,  and  the  incision  through  the  deeper  tissues  must 
be  made  through  health}-  tissue.  It  is  astonishing  how  rapidly  wounds 
heal,  and  how  quickly  patients  will  recover  after  amputations  for  exten- 
sive local  tubercular  processes,  even  in  patients  greatly  emaciated  by 
the  disease. 


CHAPTER  XXI. 

Tuberculosis  of  Tendon-Sheaths,  etc. 
tubercular  tendo-yaginitis. 

Tuberculosis  of  the  tendon-sheaths,  or,  as  Hiieter  termed  this  affec- 
tion, tendo-vaginitis  granulosa,  has  onlj-  been  recently'  recognized  and 
described  as  a  primarj'  local  tuberculosis. 

Pathology. — Hueter  -was  of  the  opinion  that  this  affection  is  seldom 
met  with  as  a  primary  lesion,  but  that  it  appears  usuall}'  as  a  complica- 
tion of  joint  tuberculosis.  As  a  secondary'  lesion  it  is  a  frequent  con- 
comitant of  osteal  and  synovial  tuberculosis  b}^  direct  extension  of  the 
inflammation  from  the  primary  focus  to  tendon-sheaths.  Yolkmann  gave 
an  able  and  accurate  description  of  tendon-sheath  tuberculosis  in  1875, 
but  at  that  time  he  was  not  aware  of  its  tubercular  nature.  The  first 
scientific  treatise  on  this  affection  came  from  the  clinic  at  Gdttingen  by 
Riedel,  who  showed  that  the  rice-bodies  so  commonly  found  in  the  so- 
called  fibrinous  h3'drops  of  the  tendon-sheaths,  or  h3'groma  of  the  flexor 
tendons  of  the  hand,  always  indicated  a  synovial  tuberculosis.  Another 
important  paper  on  the  same  subject  was  published  b}'  Beger,  who  re- 
ports 4  cases  that  occurred  in  the  clinic  at  Leipzig.  The  chronic  tendo- 
vaginitis, or  compound  ganglia  of  the  old  authors,  has  been  shown  to  be, 
on  careful  clinical  observation,  microscopic  examination,  and  bacterio- 
logical research,  cases  of  local  tuberculosis.  The  extension  of  tubercular 
processes  along  tendon-sheaths  from  a  tubercular  joint  after  perforation 
of  the  capsule  has,  for  a  long  time,  been  known  to  occur,  but  as  > 
primary  lesion  it  has  onl^' recently  been  added  to  the  long  list  of  surgical 
lesions  of  a  tubercular  character.  As  compared  with  other  tubercular 
affections,  primar^^  tendon-sheath  tuberculosis  is  quite  rare,  as  it  consti- 
tutes only  1  or  2  per  cent,  of  the  cases  in  the  statistics  of  local  tubercu- 
lar lesions.  "When  this  affection  occurs  primarih'  and  independently  of 
tuberculosis  of  an  adjacent  bone  or  joint,  infection  with  the  bacillus  of 
tuberculosis  takes  place  b}^  localization  of  floating  microbes  in  some 
small  vessel,  and  subsequently  the  pathological  processes  in  the  tendon- 
sheaths  resemble  those  of  tubercular  joints.  In  some  cases  the  products 
of  the  disease  are  massive  granulations  that  occupy-  the  inner  surface 
of  the  tendon-sheaths  ;  in  others  the  irrnn illations  are  less  .nbundnnf.  but 

(5-25) 


526  PRINCirLES   OF    SURGERY. 

u  co[)ioiis  synovuil  exudntion  is  thrown  out;  while  in  a  third  class  the 
i^ran Illations  form  hard,  white  masses,  the  so-called  corpora  orijzoidea, 
which  either  remain  attached  to  the  inner  surface  of  the  sheath,  or, 
after  their  separation,  are  found  as  loose  bodies.  In  the  form  of  tendo- 
vaginitis which  corresponds  Avith  the  fungous  variety  of  tul)ercular 
synovitis,  the  granulations  form  a  layer  of  from  1  to  4  lineB  in  thickness 
upon  the  inner  surface  of  the  sheath.  The  tendon  itself  is  covered  with 
a,  somewhat  thinner  layer  of  granulation  tissue,  the  granulations  pene- 
trating the  substance  of  the  tendon  between  the  bundles  of  connective- 
tissue  fibres,  "where,  b}-  absorption  and  pressure  atrophy,  they  cause 
extensive  destruction  of  tissue.  In  this  manner  the  tendon  becomes  so 
much  weakened  that  it  ruptures  on  the  slightest  traction,  or,  if  the  dis- 
ease has  progressed  still  farther,  the  loss  of  continuity  becomes  complete 
without  a  trauma.  The  intrinsic  tendency  of  the  disease  consists  in 
progressive  extension  by  continuity  of  structure  along  the  course  of  the 
tendon  primarily  affected,  and  when  this  tendon  is  part  of  a  compound 
tendon  the  disease  gradually  creeps  from  tendon  to  tendon  until  all  the 
sheaths  are  involved.  As  this  affection  is  met  with  most  frequently  in 
the  tendon-sheaths  surrounding  the  carpus,  and  as  these  sheaths  are  not 
infrequently  in  direct  communication  with  the  wrist-joint  by  means  of 
small  synovial  sacs,  it  extends  to  tlie  joint  by  continuity  of  surface. 
When  no  such  direct  connection  exists  between  the  tendon-sheath  and 
the  subjacent  joint,  tlie  joint  may  become  secondarily  involved  after  the 
granulations  have  perforated  the  capsule.  Next  to  the  region  of  the 
wrist-joint  the  tendo  Achillis,  the  patellar,  and  other  tendons  about  the 
knee-joint  are  most  frequently  affected.  In  tuberculosis  of  the  sheaths 
of  the  tendons  of  the  deep  flexors  of  the  fingers  the  swelling  is  often 
large,  extending  from  the  lower  portion  of  the  palm  of  the  hand  under- 
neath the  annular  ligament  to  the  middle  of  the  forearm.  Underneath 
the  annular  ligament  the  swelling  is  constricted  by  this  structure,  which 
gives  rise  to  considerable  bulging  in  the  palm  of  the  hand  and  over  the 
lower  anterior  aspect  of  the  forearm.  The  fluctuating  wave  can  be  dis- 
tinctly felt  above  and  below  the  annular  ligament,  showing  that  the  two 
swellings  are  in  direct  communication.  The  tubercular  product  under- 
goes the  same  pathological  regressive  changes  as  in  synovial  tuberculosis. 
If  a  sufficient  number  of  tubercle  bacilli  is  present  in  the  granulation 
tissue  the  cells  are  destroj^ed  by  coagulation  necrosis  and  caseation, 
tlie  fungous  masses  breaking  down  into  an  amorphous,  granular  detritus. 
At  this  stage  perforation  of  the  tendon-sheath  may  take  place  in  an  out- 
ward direction,  and  a  subcutaneous  tubercular  abscess  develops.  If  such 
abscess  open  spontaneously,  or  is  incised  without  regard  to  antiseptic 
precautions,  infection  with  pus-microbes  will  lead  to  acute  suppurative 


TUBERCULAR    TENDO-VAGINITIS.  5^7 

inflammation,  ■which  Avill  often  result  disastrously  from  rapid  extension 
of  tiie  phlegmonous  inflammation  and  septic  infection.  The  occurrence 
of  rice-bodies  in  tendon-sheath  and  synovial  tuberculosis  can  be  traced 
to  a  specific  action  of  the  bacillus  of  tuberculosis  on  the  tissues.  Kdnig 
attributes  to  this  bacillus  i)roperties  which  place  it  among  the  agents 
that  produce  fibrinous  infiammation.  The  rice-bodies  in  the  tendon- 
sheaths,  the  seat  of  a  chronic  inflammation,  he  considers  as  the  product 
of  a  fibrinous  inflammation  caused  by  the  action  of  the  bacillus  of  tuber- 
culosis. Nicaise,  Poulet,  and  Villard  examined  4  cases  of  hygroma  con- 
taining rice-bodies,  and  found  in  all  of  them  the  bacillus  of  tuberculosis. 

Symptoms  and  Diagnosis. — Tuberculosis  of  the  tendon-sheaths  is  an 
exceedingly  chronic  atlection.  The  disease  is  not  painful,  and  patients 
often  continue  to  follow  their  occupation  after  a  number  of  tendons  have 
become  involved  and  the  swelling  has  reached  considerable  dimensions. 
The  swelling  increases  in  length  in  the  direction  of  the  tendon  first 
aflfected,  and  if  the  disease  extend  to  neighboring  sheaths  it  branches 
out  in  the  direction  of  the  tendons  aflfected.  In  9  out  of  10  cases  it 
attacks  a  flexor  or  extensor  tendon  in  the  region  of  the  wrist-joint,  and 
then  extends  upward  and  downward  in  the  direction  of  the  tendons.  In 
tubercular  hj-drops  of  the  tendon-sheaths  the  swelling  often  attains  great 
size.  In  one  such  case  I  found  the  palm  of  the  hand  the  seat  of  a 
swelling,  the  size  of  a  large  orange,  that  communicated  Avith  a  smaller 
swelling  above  the  annular  ligament  of  the  wrist-joint.  In  the  fungous 
variet}'  the  swelling  imparts  to  the  palpating  finger  a  semi-elastic  resist- 
ance, and  fluctuation  is  either  entirel}-  absent  or  not  well  marked.  The 
disease  often  extends  to  the  middle  of  the  forearm,  and  in  this  locality' 
attacks  the  muscular  tissue  in  the  same  manner  as  the  tendons  farther 
below.  Extension  to  a  joint  is  attended  by  symptoms  that  point  to 
synovial  tuberculosis.  Tlie  symptoms  are  so  characteristic  that  a  correct 
diagnosis  can  often  be  made  on  first  sight.  The  only  aflTections  that 
must  be  excluded  are  the  ordinary  ganglion  of  tendon-sheaths  and  acute 
plastic  tendo-vaginitis.  A  ganglion  alwa3'S  remains  as  a  circumscribed 
swelling  without  manifesting  any  tendencies  to  extend.  The  contents 
of  a  ganglion  are  a  gelatinous  mass,  of  the  color  and  consistence  of 
clarified  hone}'.  After  evacuation  of  the  sac  no  swelling  remains,  as  the 
cyst-wall  is  not  much  thickened.  A  plastic  tendo-vaginitis,  resulting 
from  injur}'  or  overexertion,  is  an  acute  aflfection  not  attended  by  much 
eff'usion  or  inflammatory  exudation.  The  tendon-sheath  is  abnormally 
dry,  giving  rise  to  friction-sounds  which  can  be  plainly  felt  and  often 
heard  ns  the  tendon  moves  within  the  inflamed  and  roughened  sheath. 

Prognosis. — Spontaneous  cure  is  the  exception,  progressive  exten- 
sion   the  rule.     The  danger  from  regional  extension    arises    from    the 


528  PRINCIPLES   OF    SUKGERY. 

tendencies  of  tlie  disease  to  invade  adjacent  joints,  and  to  extend  from 
tendon  to  tendon,  and  finally  along  these  to  the  respective  muscles. 
There  is  no  reason  why,  occasionally  at  least,  tendon-sheath  tuberculosis 
should  not  be  followed  by  pulmonary  or  general  tuberculosis  in  conse- 
quence of  secondary  infection. 

Treatment. — The  nse  of  external  applications,  compression  and 
aspiration,  are  of  doubtful  utilit}'  in  the  treatment  of  this  aflection.  Sub- 
cutaneous evacuation,  followed  by  iodoformization,  promises  more, 
especiallj^  in  cases  of  tubercular  h3'drops  Avith  few  or  no  rice-bodies.  As 
the  rice-bodies  contain  the  essential  cause  of  the  disease,  it  will  usually 
be  found  necessary  to  remove  them  in  order  to  effect  a  permanent  cure. 
Removal  of  tliese  bodies,  as  well  as  extirpation  of  the  gniiuihition  tissue, 
can  only  be  accomplished  by  a  radical  operation.  A  radical  operation 
has  for  its  object  the  removal  of  all  of  the  infected  tissues,  which  means 
extirpation  of  the  tendon-sheath  and  erasion  of  the  granulations  that 
have  invaded  the  tendon.  No  operation  should  be  undertaken  unless  the 
surgeon  can  count  with  almost  positive  certainty  upon  aseptic  healing 
of  the  wound.  Infection  with  pus-microbes  under  such  circumstances 
would  not  only  prevent  a  satisfactory  functional  result,  but  would  place 
the  patient's  life  in  great  peril.  Fortunately,  this  form  of  surgical  tuber- 
culosis attacks  localities  where  the  surgeon  has  it  in  his  power  to  obtain, 
almost  with  absolute  certainty,  an  aseptic  healing  of  the  Avound.  Extir- 
pation of  a  tubercular  tendon-sheath  is  a  tedious  and  difficult  task.  The 
operation  must  be  made  with  the  nicety  of  a  dissection  in  the  anatomical 
room.  A  large  tenotomy  knife  and  a  small  pair  of  curved  scissors  are 
the  most  useful  cutting  instruments  in  making  the  dissection.  A  number 
of  small  tenacula  and  toothed  dissecting  forceps  are  necessary  to  retract 
tendons  and  expose  the  parts  fully  to  view.  Esmarch's  constrictor  is  an 
indispensable  aid,  as  it  renders  the  parts  perfectly  bloodless,  which 
enables  the  operator  to  identify  the  parts  concerned  in  the  dissection. 
After  the  antiseptic  precautions  have  been  completed  with  the  greatest 
care,  the  limb  is  rendered  bloodless  and  the  tendon-sheath  is  fully 
exposed  by  free  external  incision,  which  should  reach  on  both  sides  a 
little  be^'ond  the  visible  limits  of  the  disease.  The  tendon-sheatli  is  now 
slit  open,  and  the  fluid  contents  are  washed  awaj'  by  an  antiseptic 
irrigation. 

In  operating  upon  the  flexor  tendons  of  the  hand  and  fingers,  it 
often  becomes  necessary  to  divide  the  annular  ligament,  which  can  be 
done  without  fear  of  impairing  the  functional  result,  as,  after  the  opera- 
tion on  the  tendon  has  been  completed,  its  continuity  can  be  restored  by 
a  number  of  separate  buried  sutures.  The  large  arteries  and  nerves  are, 
of   course,  carefull}'  avoided.     In   order  to  remove  the  tendon-slieath 


TUBERCULAR    TENDO-VAGINITIS.  529 

completely,  it  becomes  necessary  to  liberate  the  tendon  and  to  have  it 
drawn  out  of  the  way  b3'  an  assistant.  The  removal  of  the  deep  portion 
of  the  sheath  requires  special  care,  as  it  often  is  in  close  proximity  to 
the  underlying  joint,  which  should  not  he  opened  unless  tlie  disease  has 
invaded  the  capsule  deeply.  Tlie  extension  of  the  disease  to  the  mus- 
cular tissue  can  be  readily  ascertained  from  the  naked-eye  appearances 
of  the  muscle,  which,  if  aftected,  presents  a  grayish  appearance,  and  is 
firmer  than  in  a  normal  condition.  If  the  tendon  is  extensively  infil- 
trated its  size  is  often  much  diminished  by  the  removal  of  the  infected 
portion,  which  must  be  done  with  a  sharp  tenotomy  knife.  If  several 
tendons  are  affected,  and  access  to  the  more  remote  ones  is  rendered  im- 
possible without  division  of  tlie  more  superficial  tendons,  these  can  be 
divided  and  again  united  after  the  dissection  has  been  completed.  I 
have  repeatedh-  spent  two  hours  in  an  operation  for  tendon  tuberculosis 
in  the  wu'ist-joint  region,  and  have  always  felt  that  the  time  was  well 
spent,  as  a  hast}'  operation  is  often  attended  by  unnecessary  injury  to 
contiguous  parts,  and  is  frequently  followed  by  local  recurrence  on 
account  of  incomplete  removal  of  the  infected  tissue.  Should  it  become 
uecessar}'  to  resect  a  portion  of  a  tendon  on  account  of  extensive  disease 
of  this  structure,  restoration  of  continuit}-  must  be  effected  by  an  auto- 
plastic operation.  The  tendon-end  most  suitable  for  this  purpose  is 
selected.  The  tendon  is  cut  through  one-half  at  a  distance  from  its  cut 
end  which  corresponds  with  the  length  of  the  defect,  when  it  is  sijlit 
toward  the  cut  end  to  within  a  few  lines,  and  the  piece  is  then  laid  over 
the  defect  and  sutured  at  both  ends.  After  the  removal  of  the  infected 
tissues  the  wound  is  irrigated  once  more  with  an  antiseptic  solution, 
dried,  and  iodoformized.  The  deep  fascia  is  united  separatel}'  with  buried 
sutures,  and  the  skin  is  coaptated  accurateh'  with  interrupted  stitches 
and  the  continued  suture.  A  catgut  capillary  drain  is  inserted  and  a 
copious  antiseptic  dressing  applied.  The  limb  is  placed  upon  a  well- 
padded  splint,  and,  if  no  indications  for  a  change  of  dressing  arise,  the 
first  dressing  is  allowed  to  remain  from  two  to  tliree  weeks,  when  the 
wound  will  be  found  healed  throughout.  The  functional  result  is  almost 
always  satisfactory  if  the  wound  heals  In"  primary  union.  Massage  and 
passive  motion  are  instituted  as  soon  as  the  wound  is  healed.  If  the 
operation  is  done  early  and  with  the  necessary  care,  a  local  recurrence  is 
not  to  be  expected.  For  the  purpose  of  illustrating  the  pathological 
conditions  and  the  clinical  tendencies  of  this  disease,  I  will  briefly' 
describe  one  of  the  man}'  cases  of  tendon-sheath  tuberculosis  that  have 
come  under  my  observation.  This  case  is  remarkable  on  account  of  the 
rapid  extension  of  the  disease.  The  patient  was  a  man  60  years  of  age, 
laborer,  and  addicted  to  intemperate  habits.     I  examined  him.  in  consul- 

34 


530  PRINCIPLES   OF   SURGERY. 

tation  with  his  l\iniily  physician,  about  four  months  before  the  operation 
was  performed.  At  that  time  I  found  an  oblong  swelling  on  the  dorsum 
of  the  right  hand,  corresponding  to  the  location  of  the  extensor  tendon 
of  the  index  finger.  The  swelling  was  not  painful,  and  but  little  tender 
on  pressure.  Fluctuation  was  well  marked  ;  on  deep  pressure  movable 
bodies  could  be  distinctly  felt,  which  were  recognized  as  corpora  ory- 
zoidea.  An  operation  was  advised,  but  was  declined,  as  the  patient  was 
still  able  to  follow  his  occupation.  The  swelling  was  first  noticed  six 
weeks  before  the  examination,  but  steadily  increased  in  size.  Four 
months  later  he  was  admitted  into  the  Milwaukee  Hospital,  as  the  pain 
and  the  size  of  the  swelling  now  disabled  him  from  performing  manual 
labor.  At  this  time  the  dorsum  of  the  hand  corresponding  to  the  index 
and  middle  fingers  and  the  radial  aspect  of  the  forearm  as  far  as  the 
middle  presented  a  continuous  swelling,  with  well-marked  fluctuation. 
The  swelling  had  lately  become  painful,  and  was  tender  on  pressure. 
Under  strict  antiseptic  precautions  the  swelling  was  incised  in  its  entire 
length,  and  a  large  quantity  of  synovia-like  fluid  and  softened  rice-bodies 
escaped.  The  sheaths  of  the  extensor  communis  digitorum  and  exten- 
sors of  the  wrist  were  found  lined  with  a  thick  la^^er  of  fungous  granu- 
lations, and  near  the  annular  ligament  numerous  free  and  attached  rice- 
bodies  w^ere  found.  The  tendon-sheaths  were  careful!}^  dissected  out, 
and  the  whole  wound,  after  thorough  disinfection,  was  dusted  with  iodo- 
form, drained,  and  sutured.  A  copious  dressing  of  iodoform  gauze  and 
sublimated  moss  was  applied,  and  the  forearm  and  hand  fixed  upon  an 
anterior  splint.  Healing  of  the  wound  by  primary  intention.  Almost 
complete  restoration  of  function.  No  return  after  two  years,  and  patient 
able  to  perform  hard  manual  labor.  Inoculations  of  the  fluid  upon 
potato  remained  sterile.  Cultivation  upon  coagulated  hj'drocele- serum 
showed,  after  a  few  weeks,  a  scantv  culture  of  the  bacillus  of  tubercu- 
losis. Implantation  of  one  of  the  rice-bodies  into  the  subcutaneous 
connective  tissue  of  a  guinea-pig  resulted  in  a  tj'pical  tuberculosis, 
starting  from  the  point  of  inoculation,  spreading  to  adjacent  lymphatic 
glands,  and  finally  resulting,  in  six  weeks,  in  death  from  difl"use  miliary 
tuberculosis. 

FASCIA    TUBERCULOSIS. 

The  bacillus  of  tuberculosis  has  a  special  predilection  for  fascia,  and 
primary  localization  in  this  tissue  is  a  frequent  occurrence.  It  is  a  well- 
known  clinical  fiict  that,  as  soon  as  a  deep  tubercular  focus  in  a  lymphatic 
gland,  bones,  or  joints  has  reached  the  connective  tissue  outside  of  the 
organ  primarily  affected,  the  infection  travels  along  the  connective 
tissue,  often  resulting  in  extensive  destruction  of  this  tissue  before  the 
process  reaches  the  surface.     The  extension  of  tubercular  abscesses  along 


FASCIA    TUBERCULOSIS.  531 

preformed  connective-tissue  spaces  has  been  previuusly  described.  If 
the  tubercular  product,  when  it  reaches  the  loose  connective  tissue,  is 
composed  of  living  embryonal  tissue,  the  pathological  lesions  which  are 
later  produced  in  the  connective  tissue  correspond  with  those  of  the 
primarj"^  lesion.  The  connective!  tissue  is  transformed  into  masses  of 
granulation  tissue,  which  remains  in  this  state  for  a  long  time  before  it  is 
destroyed  by  coagulation  necrosis,  with  subsequent  cell  disintegration. 
In  primary  tuberculosis  of  the  fascia  the  disease  often  spreads  with  great 
rapidity,  dipping  doAvn  between  the  muscles  along  the  intermuscular 
septa,  and  invading  from  here  the  muscles  themselves.  I  have  seen  ;> 
number  of  cases  during  the  last  few  years  where  the  disease  originated 
primarily  in  the  deep  fascia  of  the  thigh,  resulting  in  the  most  extensive 
regional  dissemination  in  the  course  of  two  or  three  years.  In  one  case, 
a  veteran  of  the  late  war,  55  years  of  age,  the  disease  commenced  at  a 
point  between  the  greater  trochanter  and  the  crest  of  the  ileum  several 
years  before  he  came  under  mj^  observation.  I  found  the  thigh  moder- 
ately swollen  with  several  prominences  from  the  crest  of  the  ileum  to 
the  knee-joint,  where  fluctuation  was  quite  distinct,  I  mistrusted  a 
primar}'  osteo-tuberculosis,  but,  on  making  free  incisions  at  different 
points,  I  found  no  evidences  of  [)rimary  tuberculosis  of  an^-  otlier  tissue 
or  organ.  The  deep  fascia  and  intermuscular  septa  were  found  destroyed, 
and  in  their  place  masses  of  granulation  tissue  presenting  foci  of  coagu- 
lation necrosis  and  caseation  invading  extensively  the  muscular  tissue. 
Yolkmann's  spoon  was  freel}'  used,  but  I  soon  found  that  this  treatment 
was  utterly-  inadequate  to  remove  all  of  the  infected  tissue,  as  the  deep 
muscles  throughout  were  extensively-  infiltrated.  Amputation  was  out 
of  the  question,  as  the  gluteal  region  as  far  as  the  crest  of  the  ileum  was 
so  extensively  affected  that  it  would  have  been  impossible  to  obtain  a 
covering  for  a  hip-joint  amputation.  lodoformization  of  the  enormous 
spaces  made  by  scraping  out  the  fungous  granulations  had  no  effect  in 
arresting  further  extension  of  the  disease.  The  patient  died,  three 
months  later,  of  general  miliary  tuberculosis. 

In  a  second  somewhat  parallel  case  the  disease  extended  from  near 
the  knee-joint  as  far  as  the  trochanter  minor.  This  patient  was  onh'  25 
years  of  age,  and  the  disease  had  existed  a  year  and  a  half.  Several 
incisions  had  been  made,  and  a  number  of  fistulous  openings  were  found 
in  communication  with  large  cavities  between  the  deep  muscles  of  the 
thigh.  The  sinuses  were  laid  open  and  scraped,  and  the  most  careful 
examination  failed  in  disclosing  a  primary  osteal  or  tendon-sheath  tuber- 
culosis. The  muscles  were  again  found  extensively  infiltrated  and  of  a 
graj'ish-white  color,  and  almost  of  gristl}'  hardness  on  being  incised. 
The  operation  rather  hastened  than  retarded  the  progress  of  the  disease, 


532  PRINCIPLES   OF    SURGERY. 

and  I  was  forced,  a  few  weeks  later,  to  amputate  the  thigh  just  below  the 
trochanters.  The  patient  made  a  slow  recovery,  but  at  the  present  time, 
two  years  after  the  operation,  he  is  in  fair  health,  and  there  is  nothing  to 
point  to  a  local  recnrrence.  I  have  learned  to  regard  fiiscia  tuberculosis 
affecting  the  intermuscular  septa  of  the  thigh  as  an  exceedingly  grave 
form  of  local  tuberculosis,  and,  if  at  all  extensive,  only  amenable  to 
successful  treatment  by  amputation. 

TUBERCULOSIS   OF    MOUTH    AND    TONGUE. 

We  have  now  every  reason  to  believe  that  many  cases  of  ulceration 
of  the  tongue,  pharynx,  and  cavit}^  of  the  mouth,  which  have  been  here- 
tofore diagnosticated  and  treated  as  carcinoma,  were  not  carcinoma,  but 
S3'philis  or  tuberculosis.  Professor  von  Esmarch,  in  a  very  able  paper, 
has  recentl}'  again  called  attention  to  the  difficulties  in  the  wa}'  in  differ- 
entiating between  these  affections. 

Pathology. — There  is  no  doubt  that  man}'  reported  cases  of  perma- 
nent recovery,  after  removal  b^-  operation  of  ulcerating  swellings  of  the 
tongue,  were  not  cases  of  carcinoma,  l)ut  tuberculosis.  Lupus  of  the 
pharynx  and  tongue  are  cases  of  local  tuberculosis.  Onh-  a  few  weeks 
ago  I  had  an  opportunity  to  examine  a  case  of  primary  tuberculosis  of 
the  pharynx  occurring  in  a  man  30  years  of  age.  The  disease  had  ex- 
isted for  four  months,  and  involved  the  posterior  wall  of  the  phar3aix, 
and  had  extended  to  the  left  tonsil.  Ragged,  deep  ulcers  had  formed, 
which  were  covered  with  flabb}^  yellowish-gray  granulations.  Numerous 
minute  miliary  nodules  could  be  seen  in  the  mucous  membrane  around 
the  ulcers,  and  on  scraping  away  the  granulations  they  were  also  found 
present  in  the  softened,  inflamed  tissues  underneath  the  floor  of  the 
ulcers.  A  beginning  hoarseness  indicated  that  the  disease  was  extend- 
ing b}'  continuity  of  tissue  to  the  larynx.  Laryngoscopic  examination 
revealed  numerous  minute  nodules,  which  studded  the  mucous  membrane 
of  the  posterior  surface  of  the  epiglottis.  The  recent  advances  made 
in  the  microscopical,  bacteriological,  and  experimental  methods  of  exami- 
nation have  succeeded  in  separating  from  syphilitic  affections  and 
malignant  disease  of  the  mouth  and  tongue  man}'  cases  that  belong  to 
the  long  list  of  affections  now  classified  under  the  head  of  surgical 
tuberculosis.  Tlie  cavity  of  the  mouth  is  often  the  seat  of  slight  abra- 
sions and  pathological  conditions,  which  ma}'  become  an  infection-atrium 
for  the  entrance  of  micro-organisms  that  might  be  contained  in  the  air 
we  breathe,  the  food  we  eat,  and  the  water  we  drink.  Remembering  the 
frequency  with  which  superficial  abrasions  and  ulcerations  occur  in  this 
locality',  it  is  not  strange  that  primary  tuberculosis  should  occasionally 
develop  here.     The  tubercle  bacillus  produces  the  same  tissue  changes 


TUBERCULOSIS   OP    MOUTH    AND    TONGUE.  533 

here  as  on  the  surface  of  the  skin,  the  primary  pathological  product  con- 
sisting of  granulation  tissue  undergoing  molecular  retrograde  tissue 
metamorphosis,  followed  by  ulceration.  Ulceration  is  an  earlier  occur- 
rence, and  a  more  conspicuous  clinical  feature  in  tuberculosis  of  the 
mouth  than  in  sunie  other  localities,  as  the  new  tissue  is  constantl}^ 
macerated  b^'  the  fluids  with  which  it  is  moistened  at  all  times.  The 
tubercular  ulcer  is  generall}^  covered  b}'  the  products  of  interstitial 
necrobiosis  and  superficial  coagulation  necrosis,  which  result  in  the 
formation  of  what  appears  as  a  false  membrane.  If  this  membrane, 
when  present,  is  removed,  the  characteristic  granulation  surface  is 
exposed.  The  ulcer  is  surrounded  hy  a  zone  of  inflammator}'  infiltra- 
tion, which,  however,  does  not  present  the  same  feeling  of  hardness  as 
carcinoma.  The  most  characteristic  feature  of  a  tubercular  ulcer  of  the 
mouth  or  tongue  consists  in  the  presence  of  minute  tubercle-nodules  in 
the  margins  and  underneath  the  layer  of  granulations,  and,  if  the  infec- 
tion has  extended  to  some  distance,  in  the  surrounding  mucous  mem- 
brane. Schliferowitsch  has  published  an  exhaustive  resume  of  the 
literature  on  this  subject  to  date,  and  has  collected  all  the  recorded  cases 
in  which  the  diagnosis  of  tubercular  disease  of  the  cavity  of  the  mouth 
could  be  made  with  some  degree  of  certaintj-.  The  cases  number  88, 
and  included  those  of  primary  and  secondary  tuberculosis.  From  a  care- 
ful study  of  this  affection  he  has  come  to  the  conclusion  that  it  occurs 
seldom  in  the  very  young,  and  that  it  attacks  most  frequentl}-  persons 
between  40  and  50  years  of  age. 

Symptoms  and  Diagnosis. — Tuberculosis  of  the  mucous  membrane 
of  the  cavity  of  the  mouth  appears  as  a  flattened,  submucous  infiltration 
composed  of  granulation  tissue,  which,  at  an  earl3'  date,  becomes  the  seat 
of  a  superficial  ulceration  in  the  centre  that  rapidl}'  extends  toward  the 
margins  of  the  swelling.  Caseation  is  seldom  observed.  The  cells  are 
destroA'ed  by  coagulation  necrosis,  and  as  the}^  become  detached  the 
defect  increases  in  size.  The  appearance  of  the  ulcer  in  this  localitj^  is 
characteristic.  If  on  the  tongue,  it  is  found  on  the  borders  near  the  tip 
of  the  organ.  It  appears  as  an  oblong  ulcer,  with  raised,  ragged  borders 
of  firmer  consistence,  showing  the  color  of  fresh  granulations.  The 
ulcer  often  appears  as  if  covered  b}-  a  pseudo-membrane;  if  this  cover- 
ing is  removed,  the  surface  left  easily  bleeds.  The  surface  of  the  ulcer 
is  uneven,  as  if  covered  with  hypertrophic  papillae.  The  discharge  of 
pus  is  slight,  and,  in  many  cases,  miliary  nodules  maj^  be  found  around 
the  ulcer.  Pain  is  not  as  severe  as  in  carcinoma.  Lymi^hatic  glands 
ma^'  become  secondarily'  infected,  but  this  is  not  often  the  case.  In  the 
primary-  form  of  the  disease,  when  a  positive  diagnosis  is  most  difl3cult, 
the  presence  of  tubercle  bacilli  will  demonstrate  the  nature  of  the  ulcer. 


53i  PRINCIPLES   OF    SURGERY. 

A  gumma  of  the  tongue,  as  a  rule,  develops  into  a  larger  swelling  than 
a  tubercular  affection  before  ulceration  takes  place,  and  the  resulting 
ulcer  is  more  deeply  excavated ;  at  the  same  time,  other  evidences  of 
syphilis  can  usually  be  detected.  Miliary  nodules  in  the  immediate 
vicinit}^  of  the  ulcer  are  absent  in  a  syphilitic  ulcer,  and  frequently 
present  in  tuberculosis.  If  any  doubt  remain  as  to  the  differential  diag- 
nosis between  these  two  affections,  this  should  be  set  aside  b}-  a  course 
of  antisyphilitic  treatment  before  resorting  to  any  serious  operation.  If 
the  ulcer  is  s^'philitic  it  will  heal  kindly  under  such  treatment,  while  no 
improvement  will  be  noticeable  if  it  is  tubercular.  Epithelioma  com- 
mences as  a  sujierlieiul  infiltration  and  penetrates  the  tissues  from  with- 
out inward.  Induration  around  and  underneath  the  ulcer  is  more 
marked  in  an  ulcerating  epithelioma  than  in  a  tubercular  ulcer.  Glandu- 
lar infection  takes  place  earl}",  and  is  almost  a  constant  occurrence  in 
epithelioma,  but  is  seldom  observed  in  the  course  of  a  tubercular  ulcer, 
A  simple  ulcer  of  the  tongue  caused  b}^  the  mechanical  irritation  from  a 
sharp  projection  of  a  carious  or  displaced  tooth  can  be  readily  recog- 
nized by  the  location  and  character  of  the  ulcer.  Such  an  ulcer  may 
become  the  seat  of  a  tubercular  ulcer  or  the  starting-point  of  an 
epithelioma. 

Treatment. — The  local  treatment  of  a  tubercular  ulcer  of  the  mouth 
or  tongue  is  the  same  as  when  a  similar  ulcer  is  located  upon  the  surface 
of  the  bod}'.  If  the  lesion  is  circumscribed  sufficiently  that  the  wound, 
after  complete  excision,  can  be  closed  by  suturing,  this  method  of  treat- 
ment should  be  adopted,  as  it  is  certainly  the  most  radical,  and  results 
most  speedily  in  complete  recovery.  If  the  extent  of  the  disease  render 
this  treatment  inapplicable,  the  diseased  tissues  should  be  removed  as 
thoroughl}'  as  possible  by  a  vigorous  use  of  the  sharp  spoon,  or  by 
destroying  it  Avith  the  actual  cautery,  or  both  of  these  measures  may  be 
combined.  The  use  of  superficial  caustics-  has  a  tendenc}'  rather  to 
aggravate  the  disease  than  to  cure  it.  With  a  sharp  spoon  all  of  the  soft 
tissues  are  scraped  awa}",  the  health}'  tissue  being  recognized  by  its 
greater  firmness  and  resistance  to  the  spoon.  After  bleeding  has  ceased, 
the  surface  is  cauterized  with  the  flat  point  of  a  Paquelin  cautery,  and, 
if  the  disease  has  dipped  in  farther  at  certain  points,  these  are  attacked 
by  making  ignipuncture  with  the  needle-point.  The  cavity  of  the  mouth, 
during  the  after-treatment,  must  be  kept  as  nearly  as  possible  in  an 
aseptic  condition  by  dusting  the  surface  daily  with  iodoform,  and  by  the 
frequent  use  of  a  mild,  antiseptic  mouth-wash,  such  as  a  saturated  solu- 
tion of  acetate  of  aluminum  or  boric  acid.  If  all  the  infected  tissues  have 
lieen  destroyed,  healing  takes  place  rapidly  by  granulation,  cicatrization, 
and  epidermization  after  separation  of  the  eschar.     If  nny  of  the  infected 


TUBERCULOSIS    OF    MUCOUS    MEMBRANE    OF    INTESTINES.        oSo 

tissues  have  remained,  the  process  of  healing  is  rt4arcled  or  completely 
arrested  ;  in  the  latter  event,  a  repetition  of  the  same  local  treatment  will 
become  necessary. 

TUBERCULOSIS   OF    THE   MUCOUS   MEMBRANE    OF   THE    INTESTINES. 

Primary  tuberculosis  of  the  intestinal  mucous  membrane  is  a  com- 
paratively frequent  affection,  but  becomes  a  surgical  lesion  only  in  case 
it  leads  to  intestinal  obstruction  or  perforation.  If,  as  is  sometimes  the 
case,  the  infection  is  limited  to  a  single  focus,  a  timely  operation  not 
only  relieves  the  symptoms  which  made  surgical  treatment  a  necessitj^, 
but  it  may  result  in  a  permanent  cure.  The  tubercular  lesions  of  the 
intestinal  mucous  membrane  that  occasionally  indicate  treatment  b}' 
laparotomy  are  usuallj'^  found  in  the  lower  portion  of  the  ileum,  the 
ileo-caical  region,  caecum,  or  ascending  colon.  Tubercular  inflammation 
of  the  large  intestine  may  cause  so  much  swelling  as  to  give  rise  to 
intestinal  obstruction.  When  the  inflammator}'  process  is  limited  to  a 
small  portion  of  the  bowel,  operative  removal  of  the  affected  segment  is 
justifiable,  and  holds  out  a  fair  prospect  of  permanent  relief.  Seiner 
reports  a  successful  case  of  this  kind.  At  the  close  of  October,  1887, 
he  was  consulted  by  a  man  who  had  a  painful  swelling  in  the  right 
hypochondrium;  the  swelling  was  as  large  as  a  man's  fist,  with  a  nodular 
surface.  Considerable  pain,  tenderness,  emaciation,  and  evidences  of 
intestinal  obstruction,  which  were  gradually  increasing  in  integrity,  A 
tumor  of  the  caecum  was  diagnosticated,  and  laparotomy  was  performed 
November  1st  of  the  same  year.  The  abdomen  was  opened  by  a  lateral 
incision.  The  omentum  near  the  swelling  was  much  inflamed  and 
covered  with  whitish-j'ellow  nodules,  from  the  size  of  a  pin  to  that  of  a 
pea.  Twelve  to  sixteen  enlarged  glands,  some  as  large  as  a  walnut, 
situated  along  the  vertebral  column,  were  enucleated  or  removed  with  a 
sharp  spoon.  The  caecum  was  so  fragile  that  it  ruptured  during  the 
manii)ulations  and  some  faeces  escaped.  The  bowel  above  and  below  the 
swelling,  which  involved  the  ctecum,  was  emptied  by  expression,  tied 
with  rubber  bands,  and  the  affected  portion  excised.  The  part  of  the 
caecum  containing  the  valve  and  the  vermiform  appendix  was  left. 
Circular  suturing  by  a  double  row  of  sutures.  The  subsequent  history' 
of  the  case  was  favorable  in  ever}-  respect.  Pain  was  severe  for  two 
days,  and  yielded  to  large  doses  of  opium.  Eighteen  months  after  the 
operation  the  patient  remained  in  good  health.  Examination  of  the  part 
removed  showed  that  the  swelling  was  of  a  tubercular  nature,  the  sub- 
mucosa  and  external  layers  of  the  bowel  being  mainly  involved. 

Durante  reported  a  somewhat  similar  case.  The  patient  was  a 
woman,  aged  56.  who,  for  four  or  Ave  ^ears,  had  suffered  from  obscure 


536  PRINCIPLES    OF    SURGERY. 

pain  in  the  right  iliac  fossa  when  at  stool.  The  pain  increased  in 
inteiisitj'  and  became  paroxysmal,  and  the  patient  almost  starved  her- 
self with  the  object  of  avoiding  the  torture  of  defecation.  On  examina- 
tion a  tumor  was  found  in  the  right  iliac  fossa,  extending  downward 
toward  the  upper  outlet  of  the  pelvis.  Carcinoma  of  the  caecum  or 
neighboring  parts  was  suspected.  The  abdomen  was  opened.  The 
swelling,  as  large  as  a  lemon,  was  found  adherent  to  the  iliac  fossa,  tiie 
parietal  peritoneum  and  coils  of  the  small  intestine  being  matted  to  it 
so  firmly  that  the  lower  end  of  the  latter,  measuring  25  centimetres  in 
length,  together  with  the  caecum  and  a  portion  of  the  ascending  colon, 
were  removed  with  it.  The  two  ends  of  the  divided  intestine  were 
brought  together  by  tliree  rows  of  sutures.  The  abdominal  wound  was 
closed,  and  the  patient  made  a  rapid  and  permanent  recovery.  The 
swelling,  which  had  almost  completely  blocked  up  tlie  lumen  of  the 
intestine,  was  found  to  be  of  a  tubercular  nature.  If,  in  cases  of  intes- 
tinal tuberculosis  indicating  laparotomy,  it  should  be  found,  after  opening 
the  abdomen,  that  the  foci  in  the  ileo-caecal  region  are  too  numerous  to 
warrant  a  radical  operation  by  enterectomy,  the  symptoms  can  be 
relieved  and  the  inflamed  parts  excluded  from  the  faecal  circulation  by 
establishing  an  anastomosis  between  the  inte?itine  above  and  below  the 
affected  segment  by  means  of  decalcified,  perforated  bone-plates. 

TUBERCULOSIS    OF   THE    MAMMARY    GLAND. 

A  number  of  well-authenticated  cases  of  primarv  tuberculosis  of  the 
mammarj'  gland  have  recently  been  reported.  So  far  as  the  infection  is 
concerned,  the  breast  must  be  considered  as  an  appendage  of  the  skin. 
The  bacillus  from  without  ma}-  effect  entrance  into  the  gland  through 
the  milk-ducts, in  which  case  the  inflammatory  process  commences  in  the 
parenchyma  of  the  gland  ;  or  it  may  enter  through  a  fissure  of  the  nipple, 
in  which  case  the  process  is  primarily  interstitial.  "When  direct  infection 
from  without  can  be  excluded,  the  disease  is  tlie  result  of  auto-infection, 
and  on  this  account  the  prognosis  is  alwa^'s  more  unfavoi'able.  Regional 
dissemination  takes  place  along  the  chain  of  axillary  Ij'mphatic  glands. 
Orthmann  examined  the  enlarged  lymphatic  glands  in  a  case  of  primary 
tuberculosis  of  the  mamma,  and  found  numerous  tubercle  bacilli.  The 
disease  is  differentiated  from  carcinoma  by  the  absence  of  pain  and 
hardness  in  the  swelling,  and  from  an  ordinar}-  suppurative  mastitis  by 
the  absence  of  the  prominent  symptoms  of  acute  inflammation.  It  might 
be  mistaken  for  a  lacteal  C3'st  or  an  echinococcus-c3-st,  but  all  doubt 
as  to  the  nature  of  the  swelling  can  be  set  aside  by  an  exploratory 
puncture. 

Treatment. — The  more  expectant  i)lans  of  treatment  recommended 


TUBERCULOSIS    OF    THE    GENITO-URINARY    ORGANS.  537 

in  the  management  of  tubercular  abscesses  conimunicnting  with  the 
primary  foci  in  tissues  and  organs  deeph'  situated  should  not  be  fol- 
lowed in  the  treatment  of  tubercular  affections  of  the  breast,  as  in  these 
cases  a  radical  operation  is  not  attended  by  any  danger  to  life,  and  usuall3' 
results  in  a  permanent  cure.  The  plan  to  be  pursued  depends  on  the 
extent  and  location  of  the  disease.  A  superficial  limited  tubercular 
focus  of  the  mamma  can  be  successfull}-  treated  by  excising  the  infected 
tissues.  If  the  process  is  more  deepl}'  located,  it  may  become  necessar}' 
to  remove  a  portion  of  the  mammar^^  gland  with  it.  Partial  excision  of 
the  gland  should  be  done  in  such  a  manner  as  to  include  tlie  tubercular 
focus  in  a  wedge-shaped  section  of  the  gland,  the  base  of  the  wedge 
being  directed  toward  the  peripiiery  of  the  gland.  After  excision  the 
cut  surfaces  of  the  gland  are  united  with  buried  catgut  sutures.  If  the 
disease  has  infiltrated  the  gland  extensivel}',  or  if  a  number  of  sinuses 
have  formed,  it  becomes  necessary  to  extirpate  the  entire  gland.  Enlarged 
glands  are  removed  in  the  same  thorough  manner  as  in  operating  for 
carcinoma  of  the  breast. 

TUBERCULOSIS    OF    THE    GENITO-URINARY   ORGANS. 

It  is  only  within  the  last  few  years  that  a  number  of  chronic  inflam- 
matorj^  processes  of  the  genito-urinary  organs  in  both  sexes  have  been 
shown  to  be  tubercular  in  their  origin,  clinical  tendencies,  and  final  ter- 
mination. The  susceptibilit}'  of  the  mucous  membrane  of  the  genito- 
urinary tract  to  tubercular  infection  has  been  demonstrated  experimentally 
by  Cornet.  In  rubbing  a  pure  culture  of  tubercle  bacilli  in  superficial 
abrasions  of  the  penis  in  dogs,  he  produced  a  tubercular  lesion  of  that 
organ.  In  bitches,  tuberculosis  of  the  vagina  and  uterus  could  be  pro- 
duced by  injection  of  a  pure  culture  into  the  vagina.  The  local  lesions 
were  followed  by  general  tuberculosis. 

(a)  Tuberculosis  of  Vulva,  Vagina,  and  Uterus.— Direct  tubercular 
infection  of  the  genital  tract  in  women  has  been  observed,  but  tlie  cases 
so  far  reported  are  few.  Barbier  believes  that  a  woman  can  be  infected 
by  a  tuberculous  man  during  coitus,  as  bacilli  have  been  demonstrated  in 
the  semen  of  tuberculous  patients,  as  well  as  in  the  discharge  attending 
tubercular  cpidid3-mitis.  The  uterus  maybe  infected  by  extension  from 
a  tubercular  lesion  of  the  vulva  without  any  intermediate  trace  of 
infection  in  the  vagina.  The  author  even  admits  the  possibilitj-  that 
tubercular  infection  maj'  be  transmitted  b^-  the  finger  of  the  attendant, 
by  infected  instruments,  or  even  through  the  medium  of  tlie  air.  Zweig- 
baum  reports  a  case  of  primary  tuberculosis  of  the  portio  vaginalis  uteri, 
which,  at  the  time  of  examination,  api)eared  in  the  shape  of  an  ulcer 
the  size  of  a  walnut,  with  thick,  indurated   margins  and  cheesy  floor. 


538  PRINCIPLES   OF    SURGERY. 

Numerous  tubercle  bacilli  were  ibuiul  in  the  secretion  taken  from  the 
surface  of  the  ulcer.  Evidences  of  tuberculosis  were  apparent  at  this 
time.  After  a  few  weeks  the  ulcer  extended  toward  the  left  vaginal  wall 
and  left  labia  majora.  A  section  of  a  fragment  of  tissue  removed  from 
these  parts,  on  staining,  showed  numerous  bacilli.  This  form  of  tuber- 
culosis is  not  frequent,  as  the  author  could  lind  only  2  cases  of  vulvo- 
tuberculosis  in  literature,  although  genital  tuberculosis  is  quite  a  frequent 
atfection.  Jonin  believes  that  tubercular  endometritis  from  local  infec- 
tion is  quite  a  common  affection.  Of  9  cases  which  were  observed  by 
him  it  was  due  to  sexual  contact  with  men  suffering  from  genital  tuber- 
culosis. In  2  others  the  husbands  were  tuberculous,  but  had  no  genital 
tuberculosis.  He  calls  attention  to  the  fact  that  Cornil  and  Chantemesse 
have  produced  this  disease  artificially  in  rabbits  by  injecting  bacilli  into 
the  vagina.  The  cases  of  primary  tuberculosis  of  the  vulva,  vagina,  and 
uterus  will  undoubtedly  become  more  numerous  in  the  literature  of  the 
near  future,  when  Improved  methods  of  examination  will  enable  the 
surgeon  to  make  a  positive  diagnosis  between  these  affections  and  carci- 
noma and  syphilitic  lesions.  The  same  points  in  differential  diagnosis 
are  to  be  remembered  in  this  connection  as  have  been  enumerated  in  the 
consideration  of  tubercular  affections  of  the  mouth. 

Treatment. — Primary  tuberculosis  of  the  utero-vaginal  canal  and 
vulva  should  be  treated  by  curetting,  and,  if  the  extent  of  tlie  lesions 
make  it  necessar}^  b}'  cauterization  with  the  actual  cautery.  Before 
either  of  these  procedures  are  put  into  practice,  the  parts  must  be  ren- 
dered aseptic  b}'  antiseptic  irrigation.  Sul)sequent  infection  can  be 
guarded  against  b3'  the  free  use  of  iodoform,  and  tamponade  of  the 
vagina  with  iodoform  gauze.  Under  ordinary  circumstances,  it  is  not 
necessary  to  remove  the  tampon  oftener  than  once  a  week,  when  the 
surface  is  again  freely  dusted  with  iodoform  before  a  new  tampon  is 
inserted. 

(b)  Tuberculosis  of  Fallopian  Tubes. — In  the  absence  of  tubercular 
lesions  of  the  vagina  and  uterus,  it  is  doubtful  if  infection  of  the  Fallopian 
tubes  can  take  place  b}-  the  entrance  of  the  bacillus  through  the  genital 
tract,  and  the  relatively  frequent  occurrence  of  the  disease  in  that  part 
of  the  genital  tract  is  only  explainable  by  attril)uting  it  to  auto-infection, 
in  the  same  way  as  w^e  have  explained  the  occurrence,  for  instance,  of 
primary  tuberculosis  of  joints,  bone,  and  peritoneum.  We  can  safely 
assert  that  tubercular  infection  of  the  Fallopian  tubes  often,  if  not 
always,  takes  i)lace  upon  the  basis  of  pre-existing  pathological  conditions, 
taking  it  for  granted  that  the  health}^  tubes  do  not  present  favorable 
conditions  for  the  localization  of  the  tubercle  bacilli.  A  catarrhal  con- 
dition of  the  mucous   membrane  lining  the  tubes,  as  in  other  organs, 


TUBERCULOSIS    OF    THE    GENITO-URINARY    OKGANS.  539 

undoubtedly  furnishes,  in  many  instances,  the  locux  minoris  resistentiae 
for  the  localization  of  bacilli  brought  to  the  part  through  the  circulating- 
blood. 

An  interesting  case  of  primary  tuberculosis  of  the  Fallopian  tubes 
has  been  recorded  by  Kotschau.  The  patient  was  45  j-ears  old,  having 
;i  good  family  history  ;  has  surtered  for  a  year  with  pains  in  the  abdomen, 
l)rofuse  metrorrhagia,  and  various  nervous  disturbances.  Slie  was 
treated  for  retroflexion,  and  subsequently  had  an  attack  of  pelveo- 
peritonitis.  Vaginal  examination  disclosed  a  firm,  smooth,  movable 
swelling,  as  large  as  an  apple,  to  the  right  of  the  uterus  ;  tliis  was  taken 
for  a  malignant  ovarian  growth,  and  laparotomy'  was  done  for  its  removal. 
On  opening  the  abdominal  cavity,  a  quantity  of  turbid,  purulent  fluid 
escaped.  The  swelling,  of  oblong  shape,  was  found  lying  apparently  in 
a  bed  of  pus ;  on  account  of  its  intimate  adhesions  it  could  not  be 
removed.  The  patient  died  from  shock.  The  autopsy  showed  the 
uterus  enlarged  aud  retroverted.  The  right  tube  was  tortuous  and  gen- 
erally thickened.  Near  its  distal  end  it  was  dilated  into  a  swelling  the 
size  of  a  hen's  egg^  in  the  centre  of  which  was  a  cavity  containing  cheesy 
material.  Other  smaller  caseous  foci  were  found  in  the  tubal  wall  in 
close  proximity  to  the  large  swelling.  The  ovary  on  the  same  side  was 
enlarged  aud  transformed  into  a  caseous  mass.  The  left  tube  and  ovary 
showed  similar  changes,  though  less  extensive.  The  microscopic  exami- 
nation of  the  pathological  product  confirmed  the  diagnosis  of  tubercu- 
losis. Although  the  disease  appears  to  have  been  primary  in  the  tubes, 
the  affection  occurs  more  frequently  from  the  direct  extension  of  a  tuber- 
cular endometritis  to  the  tubes.  LebedeflT  gives  a  full  description  of  a 
case  that  came  under  his  observation.  The  patient  was  the  widow  of  a 
man  who  had  died  of  pulmonary  tul)erculosis.  An  examination  before 
the  operation  revealed  a  firm,  nodulated,  intra-abdominal  tumor  in  the 
space  of  Douglas.  An  attempt  was  made  to  remove  the  tumor  b}' 
laparotom}',  but  had  to  be  abandoned,  as  the  disease  had  become  too 
widely  disseminated.  Six  weeks  later  the  patient  died  with  symptoms 
of  general  tuberculosis.  At  the  post-mortem  miliary  tuberculosis  was 
found  in  the  peritoneum,  lungs,  colon,  uterus,  and  Fallopian  tubes.  The 
most  advanced  stages  of  the  disease  were  found  in  the  uterus  and  Fallo- 
pian tubes,  showing  that  the  disease  had  commenced  in  these  organs. 
Both  of  the  Fallopian  tubes  were  dilated  and  filled  with  pus,  the  epithe- 
lium in  parts  being  absent.  Stained  sections  from  the  uterus  and  tubes 
showed  the  presence  of  numerous  bacilli. 

Symptoms  and  Diagnosis. — Tubercular  salpingitis,  occurring  as  a 
secondary  lesion  to  a  primary  tuberculosis  in  the  lower  portion  of  the 
genital   tract,  can   be  suspected    if,  in   connection   with   a  cervical    or 


54:0  PKINCJPLES    OF    SUKGEKY. 

endometritic  tuberculosis,  examination  revenl  a  swelling  in  the  region  of 
one  or  botli  Fallopian  tubes.  Primary  tubercular  disease  of  the  Fallo- 
pian tubes  gives  rise  to  local  conditions  and  sj'mptoms  tliat  it  would  be 
impossible  to  differentiate  from  an  ordinary  p^-osalpinx.  Tlie  existence 
of  a  dilated,  inflamed  Fallopian  tube  can  generally  be  made  out  with 
some  degree  of  certainty  by  making  the  examination  while  the  patient 
is  under  the  influence  of  an  anaesthetic.  Werth  has  described  an  acute 
and  chronic  form  of  tubercular  salpingitis.  In  the  acute  variety  both 
the  muscular  and  serous  coats  undergo  caseous  degeneration,  numerous 
bacilli  being  found  in  tlie  interior  of  the  tube  ;  while  in  the  chronic  form 
the  wall  of  the  tube  undergoes  thickening  and  infiltration  with  new  cells, 
and  its  contents  contain  only  a  few  bacilli.  Tlie  increase  in  size  of  the 
tube  is  due  to  the  collection  of  pus  in  its  interior  as  well  as  to  the  thick- 
ening of  the  wall.  When  suppuration  takes  place  in  the  interior  of  the 
tube  the  tubercular  product  has  become  the  seat  of  a  secondary  infection 
with  pus-microbes  ;  hence,  indications  for  operative  treatment  have  become 
more  urgent.  If  the  tubercular  inflammation  extend  from  the  abdominal 
extremity  of  the  Fallopian  tube  to  the  peritoneum,  symptoms  of  tubercular 
salpingitis  are  obscured  later  on  by  those  of  tubercular  peritonitis. 

Treatment. — As  a  tubercular  salpingitis  calls  for  the  same  treatment 
as  a  pyosalpinx,  it  is,  for  all  practical  purposes,  only  necessary  to  narrow 
the  diagnosis  down  to  either  one  of  those  two  affections  before  resorting 
to  treatment  by  lai);irotom3'.  A  median  incision  is  preferable  to  a  lateral, 
as  frequentl}^  both  tubes  are  affected  simultaneously.  Salpingectomy 
should  be  combined  with  oophorectomy,  as  the  ovaries  are  frequently 
implicated  in  the  tubercular  process,  and  these  organs  would  be  of  no 
further  use  after  extirpation  of  the  tubes.  As  tubercular  tubes  are  usually 
found  firmly  adherent  to  the  surrounding  tissues,  their  removal  is  often 
attended  with  the  greatest  difficulties,  and  maj'  become  an  impossible 
task.  If  the  disease  is  limited  to  the  tul^e-structures,  and  has  not  in- 
volved surrounding  important  organs,  it  would  appear  rational,  under 
such  circumstances,  to  la^-  the  tube  open,  remove  its  contents,  scrape  out 
the  infected  tissues  as  far  as  possible,  arrest  bleeding  by  applj'ing  the 
actual  cauter}',  and,  after  thorough  iodoformization,  pack  Avith  iodo- 
form gauze.  This  treatment  would  certainly  appear  more  rational  than 
to  be  content  with  an  exploratory  incision,  and  allow  the  patient  to  re- 
main a  sufferer  until  relieved  bj'  death  from  tuberculosis.  In  one  case 
that  came  under  in}'  treatment,  where  both  tubes  were  imbedded  in  a 
mass  of  granulation  tissue,  I  was  unable  to  remove  the  entire  mass, 
was  compelled  to  pursue  this  course,  and  the  patient  recovered  quickly 
and  permanently-,  in  spite  of  a  faecal  fistula  that  formed  a  few  days  after 
the  operation. 


TUBERCULOSIS    OF    GLANS    PENIS    AND    URETHRA.  oJrl 

TUBERCULOSIS  OF  GLANS  PENIS  AND  URETHRA. 
Kraske  has  observed  a  case  of  tubercular  ulceration  of  the  urethra, 
extending  from  the  membranous  portion  to  the  neck  of  the  bladder,  in 
a  patient,  33  ^ears  of  age,  who  was  treated  for  chancre.  The  autopsy 
revealed  advanced  tuberculosis  of  the  genito-urinary  tract  and  pulmonary 
tuberculosis.  In  another  case,  a  man  49  years  old,  a  tubercular  ulceni- 
tion  existed  on  the  dorsum  of  the  glans  the  size  of  a  cent  piece.  This 
sore  was  also  mistaken  for  a  primar3'  lesion  of  syphilis.  There  were  no 
signs  of  pulmonary  tuberculosis.  The  glans  was  amputated,  when  it 
was  observed  that  the  tubercular  infiltration  extended  deepl}'  into  the 
cavernous  structure.  The  lesion  could  not  be  traced  to  genital  contact, 
and  under  the  microscope  showed  the  typical  structure  of  tubercular 
tissue.  In  the  examination  of  doubtful  lesions  of  the  glans  penis,  it  is 
well  to  remember  the  possibility  of  tubercular  infection  in  this  locality, 
and,  in  case  the  tubercular  nature  of  a  lesion  can  be  established  on  suffi- 
cient grounds,  to  resort  to  cauterization  with  the  actual  cautery,  excision, 
or  amputation,  according  to  the  location  and  extent  of  the  disease. 

TUBERCULOSIS  OF  EPIDIDYMIS  AND  TESTICLE. 
In  the  male  genital  apparatus  tuberculosis  attacks  most  frequently 
the  epididymis,  for  the  reason  that  the  vessels  in  this  structure  are  more 
tortuous  and  smaller  than  in  the  remaining  portion  of  the  testicle  or  the 
vas  deferens,  both  of  which  are  important  elements  in  determining  locali- 
zation in  that  part  from  floating  bacilli  that  reach  it  through  the  circu- 
lating blood.  Saltzmann  states  that  these  anatomical  conditions  are  im- 
portant factors  in  the  arrest  and  localization  of  floating  bacilli.  That  in 
cases  of  tuberculosis  of  the  testicle  we  are  only  dealing  with  an  external 
manifestation  of  an  antecedent  infection  becomes  apparent  by  the  clini- 
cal observation  that  not  infrequently'  both  testicles  are  infected,  either 
simultaneouslj'  or  some  time  apart,  showing  that  the  infection  came  from 
the  same  source.  Tuberculosis  of  the  genital  organs  in  the  male  fur- 
nishes one  of  the  best  examples  of  the  t^'pical  clinical  course  of  local 
tuberculosis.  The  disease  extends  by  continuity  of  structure  often  to  a 
great  distance  from  its  starting-point.  Nothing  is  more  familiar  than 
the  clinical  course  of  a  case  of  tuberculosis  of  the  testicle.  A  sm.nll, 
hard  nodule  is  first  detected  in  the  epidid^nnis,  and  from  this  point  the 
whole  structure  of  the  epididymis  is  infected,  when  the  infection  slowly, 
but  surel}',  extends  to  the  testicle ;  then  along  the  vas  deferens  to  the 
vesiculje  seminalis,  the  prostate  gland,  and  bladder,  and  from  this  viscus 
along  the  ureters  to  the  pelvis  of  the  kidney.  As  a  rule,  the  disease 
remains  limited  to  the  genito-urinary  organs,  but  in  some  instances 
metastatic  infection  takes  place,  either  from  the  genito-urinary  organs  or 


5  +  2  rKINCIPLES    OF    SURGERY. 

from  the  prinuiry  source  of  infection.  A  gentleman  was  recently  unrler 
my  care  whose  case  illustrates  a  number  of  interesting  poiwts  descriptive 
of  the  clinical  behavior  of  genital  tuberculosis.  He  was  35  years  of  age  ; 
married  for  ten  years;  the  marriage  had  been  childless.  He  claimed  that 
he  never  had  syphilis  or  gonorrliosa.  Tuberculosis  is  hereditar}'  in  the 
familv.  Nine  years  ago  he  noticed  a  small,  hard  swelling  in  the  epididy- 
mis of  both  testicles.  Two  years  ago  symptoms  of  cystitis  appeared, 
which  were  not  much  improved  1)3'  internal  medication  and  antiseptic 
irrigation  of  the  bladder.  Six  months  ago  his  left  knee  became  swollen 
and  painful.  Four  months  later  he  commenced  to  suffer  severe  pain  in 
the  region  of  the  left  kidney.  Temperature  varied  from  100^  to  103°  F. 
A  swelling  soon  formed  in  the  left  lumbar  region,  and  four  weeks  later  I 
evacuated  a  large  quantity  of  pus  through  a  lumbar  incision.  Through 
the  incision  the  kidney  could  be  seen  and  felt,  and,  by  passing  the  index 
finger  around  it,  it  appeared  to  be  extensively  separated  from  the  con- 
tiguous structures.  The  left  knee  presented  all  the  appearances  of  ad- 
vanced synovial  tuberculosis.  No  evidences  of  pulmonary  tuberculosis. 
The  disease  in  both  testicles  had  made  no  progress  for  j^ears,  and  the 
infiltration  appears  to  be  limited  to  the  epididj-mis.  The  epididymis  on 
both  sides  is  moderately  swollen  and  indurated.  The  vas  deferens  on 
each  side  is  somewhat  larger  and  firmer  than  normal.  The  disease  had 
extended  from  the  epididymis  to  the  pelvis  of  the  kidne3'  on  both  sides, 
all  of  the  intervening  organs  being  involved  in  the  tubercular  process. 
The  only  apparent  manifestation  of  general  tuberculosis  was  presented 
by  the  left  knee.  An  interesting  feature  in  this  case  was  the  formation 
of  a  paranephritic  abscess  around  a  pyelo-nephritic  kidney,  which  must 
be  regarded  as  the  result  of  a  secondary  infection  with  pus-microbes. 

Symptoms  and  Diagnosis. — Tubercular  epidid3'mitis  alwa3S  appears 
as  a  chronic  affection,  in  this  respect  differing  from  gonorrhoeal  epidid3'- 
mitis  and  the  ordinar3'  form  of  acute  parenchymatous  and  suppurative 
orchitis.  Pain  and  tenderness  are  either  entirely  absent  or,  at  least, 
slight  when  present.  Circumscribed  hydrocele  may  develop  as  soon  as 
the  disease  extends  to  the  tunica  vaginalis.  The  tubercular  inflamma- 
tion is  characterized  by  the  same  pathological  conditions  as  in  other 
organs,  new  nodules  appearing  in  the  neighborhood  of  the  first  one, 
which,  b3^  confluence,  form  masses  of  considerable  size.  Caseation  is  an 
earl 3^  and  almost  constant  condition.  In  many  cases  the  process  extends 
in  the  direction  of  the  skin  ;  a  tubercular  abscess  forms  in  the  tunics  of 
the  scrotum ;  the  skin  presents  a  bluish-red  color,  and  spontaneous  perfo- 
ration gives  rise  to  evacnation  of  the  abscess.  Frequentl3'-  multiple 
abscesses  form  in  this  manner,  and  the  fistulous  openings  lead  down  to 
caseous  masses.     In  some  cases,  as  the  one  reported,  the  disease  in  the 


TUBERCULOSIS    OF    THE    VESICUL.1-:    SKMINALIS.  543 

epididymis  becomes  latent,  but  the  infection  extends  at  an  early  date 
along  the  vas  deferens,  which  becomes  swollen  and  indurated,  and  from 
which,  if  a  cross-section  is  made,  the  characteristic  chees}^  material  can 
be  squeezed.  From  the  vas  deferens  the  disease  extends  to  the  vesiculae 
seminalis,  prostate  gland,  bladder,  and  finally  creeps  along  the  ureters 
to  the  pelvis  of  the  kidney,  usually  simultaneous!}'  on  both  sides.  The 
only  disease  with  which  tubercular  epididymitis  might  be  confounded  is 
tertiary  syphilis,  affecting  the  same  part  of  the  testicle.  In  cases  of 
doubt  the  patient  should  be  placed  on  antisyphilitic  treatment  for  a  few 
weeks,  which,  if  the  affection  is  tubercular,  will  produce  no  impression 
on  the  swelling  ;  on  the  other  hand,  if  it  is  syphilitic,  it  will  rapidly 
diminish  in  size. 

Treatment. — The  only  radical  treatment  in  tuberculosis  of  the  epi- 
didymis and  testicle  is  castration.  This  operation  is  indicated  if  the 
disease  is  limited  to  one  testicle,  and  no  evidences  of  tuberculosis  can 
be  found  in  anj-  other  organ  beyond  the  reach  of  surgical  treatment.  I 
liave  removed  both  testicles  in  two  cases,  but  in  both  patients  tubercular 
cystitis  developed  one  and  two  years,  respectivel}',  after  the  operation, 
and  in  one  of  them  the  immediate  cause  of  death  was  pulmonary  tubercu- 
losis. Mv  own  cases  and  the  experience  of  other  surgeons  would  tend 
to  dictate  a  conservative  course  of  treatment  if  both  testicles  are 
affected.  After  the  disease  has  extended  to  the  organs  at  the  base  of  the 
bladder  or  the  bladder  itself,  castration  is.  of  course,  positively  contra- 
indicated.  The  co-existence  of  pulmonar}'  tuberculosis,  or  tuberculosis 
of  any  of  the  larger  joints,  would  furnish  a  sufficient  ground  against  the 
propriety  of  castration.  Castration  is  a  legitimate  operation,  and  yields 
fair  results  if  the  patient  is  otherwise  in  good  health  and  the  disease  is 
limited  to  one  side,  and  has  not  extended  along  the  cord  be^'ond  a  point 
where  all  of  the  infected  tissues  can  be  removed.  The  tunica  vaginalis 
should  always  be  removed  with  the  testicle,  and,  if  the  scrotum  is 
adherent  at  anj'^  point,  the  adherent  portions  of  the  skin  must  be  excised 
at  the  same  time.  In  removing  the  testicle  for  tuberculosis,  it  is  always 
necessary  to  carr}^  the  incision  as  far  as  the  internal  ring,  in  order  to 
remove  as  much  as  possible  of  the  cord.  The  vessels  of  the  cord  should 
be  tied  separately,  as  tying  the  cord  en  masse  gives  rise  to  unnecessai-y 
pain,  and  the  ligature  is  liable  to  slip, — an  occurrence  that  might  be 
followed  b}'  troublesome  hfemorrhage. 

TUBERCULOSIS  OF    THE   VESICUL^    SEMINALIS. 
In  1829  Dahmar  described  a  chronic   inflammation   of  the   seminal 
vesicles,  the  description  of  which  corresponds  closely  to  that  of  tubercu- 
losis.    Since  then  this  affection  has   been  described  by  Aibers,  Jaye, 


54:4  PRINCIPLES    OF    SURGERY. 

Naumunn,  Humpliro}-,  and  Kocher,  and  latel3'  it  has  been  studied  by 
Raver,  Cruveilhier,  and  lleclus  as  secondary  to  pulmonary  tuberculosis. 
As  a  secondary  affection  this  ailment  is  not  only  seen  in  connection  with 
tuberculosis  of  the  lungs,  but  is  n)ore  common  after  primary  tubercu- 
losis of  the  epidid3'mis,  either  as  a  continuation  of  the  cheesy  degenera- 
tion in  the  vas  deferens  or  spreading  by  contiguity  of  tissue  from  the 
sides  of  the  prostate.  Primary  tuberculosis  of  these  organs  is  ex- 
tremely- rare,  and  still  less  often  diagnosed,  and  up  to  quite  recently  no 
surgical  interference  has  been  attempted.  Ullmann  now  reports  a  case 
of  primary  tuberculosis  of  the  right  testicle,  with  secondary  affection 
of  the  seminal  vesicles  on  both  sides,  in  a  lad  It  years  of  age,  where, 
after  removal  of  the  right  testicle,  he  extirpated  these  organs  through  a 
semi-lunnr  incision  in  the  perineum.  The  general  health  of  the  patient 
improved  after  the  operation,  but  a  small  urinary  fistula  remained,  which 
formed  in  consequence  of  injury  to  the  base  of  the  bladder  during  the 
operation.  He  is  of  the  opinion  tliat  the  seminal  vesicles  should  be  re- 
moved in  primary-  tuberculosis  of  the  testicle  or  epididymis,  when  no 
suspicious  symptoms  have  appeared  on  the  sound  side,  and  when  on  the 
affected  side  the  vesiculae  seminalis  are  already  attacked  ;  also  in  cases  of 
primary  tuberculosis  of  the  seminal  vesicles.  Tlie  impotence  following 
the  operation  should  be  no  contra-indication,  for  in  all  reported  cases  of 
tuberculosis  of  the  seminal  vesicles  impotence  always  occurs  in  a  short 
time  ;  in  fact,  it  is  regarded  as  a  cardinal  sj^mptom  of  the  disease. 

TUBERCULOSIS  OF  THE  BLADDER. 

Tuberculosis  occurs  either  as  a  primar}-  or  secondary  affection. 
Several  cases  of  well-marked  primary  tuberculosis  of  the  bladder  in 
the  female  have  come  under  ni}'  observation,  where  the  disease  evidently 
commenced  at  the  neck  of  the  bladder,  and,  after  spreading  over  the 
whole  internal  surface  of  the  viscus,  extended  along  the  ureters  to  the 
pelves  of  the  kidneys,  and,  finally,  in  the  course  of  a  few  years,  proved 
fatal  from  tubercular  pyelo-nephritis.  Primary  tubercular  cystitis  appears 
to  be  more  frequent  in  females  than  in  iiinles.  undoubtedly  because,  on  ac- 
count of  shortness  of  the  urethra,  direct  infection  is  more  liable  to  occur. 

Striimpell,  after  a  careful  study  of  4  cases  of  primary  tuberculosis 
of  the  bladder  in  men,  came  to  the  conclusion  that  infection  takes  place 
through  the  urethra.  The  tubercle  bacilli, finding  no  favorable  place  for 
localization  and  growth  in  the  urethra  and  bladder,  finally  reach  the 
prostate  gland  or  the  epididymis,  the  whole  process  resembling  what 
occurs  in  inhalation  tuberculosis,  in  which  the  disease  manifests  itself 
not  in  the  mucous  membrane  of  the  bronchial  tubes,  but  in  the  paren- 
chyma of  the  apices  of  the  lungs. 


TUBERCULOSIS  OF  THE  BLADDER.  545 

Symptoms  and  Diagnosis. — Tuberculosis  of  the  bladder  is  clinically 
characterized  b}'  symptoms  of  cystitis,  the  intensity  of  the  S3^mptoms 
varying-  according  to  the  part  of  the  bladder  affected,  the  extent  of  the 
disease,  and  the  presence  or  absence  of  complications.  If  the  disease 
primaril}'  involve  the  neck  of  the  bladder,  tenesmus  and  frequent  desire 
to  urinate  are  the  most  distressing  symptoms.  As  long  as  no  ulceration 
of  the  vesical  mucous  membrane  has  taken  place,  the  urine  ma}^  present 
a  perfectly  normal  appearance,  and,  on  examination,  is  found  normal  in 
other  respects.  Very  frequently  the  symptoms  become  ver}-  much 
aggravated  shortly'  after  an  examination  of  the  bladder,  made  upon  the 
supposition  that  the  patient  is  suffering  from  stone  in  the  bladder,  as  the 
introduction  of  a  sound  without  the  necessar}'  antiseptic  precautions  is 
often  followed  by  a  secondary  infection  with  pus-microbes,  which  gives 
rise  to  an  acute  suppurative  cystitis.  The  general  health  of  the  patient 
now  becomes  rapidly  undermined,  and  the  extension  of  the  local  disease 
in  the  direction  of  the  kidne^-s  is  hastened.  The  urine  contains  large 
quantities  of  pus  and  mucus,  and  becomes  ammoniacal  from  the  presence 
and  action  of  putrefactive  bacteria.  The  walls  of  the  bladder  become 
greatly  thickened  from  inflammator}-  exudation  and  tubercular  infiltra- 
tion; the  organ  is  unable  to  empty  itself  completely,  and  the  decomposed 
residual  urine  becomes  an  additional  source  of  irritation  and  progressive 
infection.  Incontinence  of  urine  is  a  frequent  S3^mptom  in  advanced 
vesical  tuberculosis,  and  is  usuall}'  an  indication  that  the  organ  is  ex- 
tensively diseased.  In  secondar}'  tuberculosis  of  the  bladder  it  is  usually 
not  difficult  to  locate  the  primary  disease,  and  thus  establish  a  positive 
diagnosis.  The  presence  of  tubercle  bacilli  in  the  urine  in  cases  of 
primary  tuberculosis  of  the  organ  furnishes  a  positive  diagnostic  crite- 
rion between  ordinary  cystitis  and  vesical  tuberculosis.  In  the  absence 
of  ordinar}'  causes  of  cystitis,  such  as  gonorrhoea,  stricture  of  the  ure- 
thra, enlarged  prostate,  calculus,  and  tumors  of  the  bladder,  symptoms 
of  cystitis  point  strongl}^  toward  a  tubercular  origin  of  the  inflammation, 
and  should  induce  the  surgeon  to  make  a  most  careful  examination  in 
reference  to  the  etiology  and  nature  of  the  C3'stitis.  It  is  only  by  ex- 
cluding the  presence  of  the  different  lesions  of  the  bladder  b}-  a  careful 
and  thorough  examination  of  that  viscus  and  its  neighboring  organs,  as 
well  as  a  chemical,  microscopical,  and  bacteriological  examination  of  the 
urine,  that  a  positive  diagnosis  of  vesical  tuberculosis  can  be  made  during 
the  early  stages  of  the  disease.  Tuberculous  urine  injected  into  the 
peritoneal  cavity  of  a  guinea-pig  will  produce  tuberculosis  in  this  animal, 
and  in  doubtful  cases  this  diagnostic  measure  may  prove  of  great  value. 

Prognosis  and  Treatment. — In  secondary  tuberculosis  of  the  bladder 
the  regional  infection    has  extended  so  far  that  even  the  most  heroic 


546  PRINCIPLES   OF    SURGERY. 

surgical  measures  will  necessarily  fail  in  eliminating  the  disease,  and 
death  from  extension  of  the  disease  to  the  kidneys,  or  from  secondary 
pulmonary  or  general  tuberculosis,  will  follow  as  an  inevitable  result.  In 
primary  vesical  tuberculosis,  the  disease,  at  tlie  time  a  positive  diagnosis 
can  be  made,  has  usually  invaded  so  much  of  the  walls  of  the  bladder 
that  a  radical  operation  would  necessitate  an  extensive  resection  of  its 
walls,  after  which  it  would  be  found  impossible  to  utilize  the  remaining 
portion  of  the  organ  as  a  reservoir  for  the  urine.  Resection  of  the  wall 
of  the  bladder  has  been  done  in  several  instances  in  the  treatment  of 
malignant  tumors  at  its  base,  but  have  usually  terminated  in  the  formation 
of  a  permanent  urinar}'  fistula. 

Dr.  R.  Harvey  Reed,  of  Mansfield,  Oliio,  has  recentl}'  made  an  in- 
teresting series  of  experiments  on  dogs,  with  a  view  to  dispense  with 
the  bladder  altogether  in  cases  of  extensive  disease  of  this  organ,  neces- 
sitating partial  or  complete  excision.  He  has  shown  that  the  ureters  can 
be  successfully  implanted  intc  the  rectum,  thus  excluding  permanenth- 
the  urinary  tract  below  this  point  from  the  urinary  passages,  and  utiliz- 
ing the  rectum  as  a  reservoir  for  the  urine.  If  the  operation  of  im- 
plantation of  the  ureters  into  the  rectum  can  be  perfected  to  such  an 
extent  as  to  become  a  feasible  and  practical  procedure  in  surgery,  it  may 
be  possible,  in  the  future,  that  vesical  tuberculosis  can  be  successful!}'' 
dealt  with  by  complete  excision  of  the  affected  organ. 

The  conservative  treatment  of  vesical  tuberculosis  by  injection  of 
solutions  of  boric  acid,  benzoate  of  soda,  the  ordinar}^  antiseptic  solu- 
tions, and  iodoform  has  little  or  no  effect,  either  in  aflfording  palliation 
or  in  retarding  the  regional  extension  of  the  disease.  Internal  medicines, 
such  as  boric  acid,  benzoate  of  soda,  uva  ursi,  buchu,  and  triticum  repens, 
are  of  utility  in  relieving  vesical  tenesmus,  before  secondary  infection 
with  pus-microbes  and  putrefactive  l)acteria  has  occurred,  by  rendering 
the  urine  alkaline  and  more  copious  ;  but  during  the  later  stages  of  the 
disease  they  are  useless  even  as  palliatives.  If  the  tubercular  process 
is  limited  to  the  urinar^^  passages  below  the  ureters,  incision  and  drainage 
of  the  bladder  secure  rest  to  this  organ  and  open  up  a  direct  route  for 
the  more  eftectual  treatment  of  the  tubercular  lesions,  and  thus  not  onh' 
constitute  the  most  efficient  palliative  measure,  but  also  the  most 
effective  procedure  in  retarding  tiie  local  extension  of  the  disease  b}^ 
direct  vigorous  antitubercular  treatment.  I  had  an  opportunity  to 
observe  the  palliative  effect  of  an  opening  in  the  bladder,  in  a  case  of 
primary'  vesical  tuberculosis  in  a  female  aged  35  years,  where  the  tuber- 
cular ulceration  resulted  in  the  formation  of  a  vesico-vaginal  fistula. 
The  tenesmus  was  promptly  relieved,  as  soon  .is  the  l)ladder  was  placed  in 
a  condition  of  rest,  by  the  escape  of  urine  through  the  fistulous  opening. 


TUBERCULOSIS    OF    THE    BLADDER.  547 

In  the  female  the  most  direct  route  into  the  bladder,  and  aflurding 
the  most  efficient  drainage  and  furnishing  the  most  advantageous  con- 
ditions for  the  local  treatment  of  the  tubercular  lesions,  is  a  vaginal 
cj'stotom}'  made  near  the  neck  of  the  bladder.  The  opening  should  be 
at  least  1^  inches  in  length,  extending  from  near  the  neck  of  the  bladder 
in  an  upward  direction.  Tubular  drainage  should  be  dispensed  with,  as 
all  foreign  substances  in  the  bladder  not  only  act  as  irritants,  but  interfere 
Mith  complete  drainage.  As  the  opening  is  made  in  the  most  dependent 
portion  of  the  bladder^  free  drainage  can  be  secured  most  efficientl}'  bv 
means  which  prevent  contraction  or  closure  of  the  vesico-vaginal  open- 
ing. This  can  be  done  by  suturing  the  mucous  membrane  of  the  bladder 
to  the  vaginal  mucous  membrane,  thus  establishing  a  permanent  bimu- 
cous  fistula  between  the  bladder  and  the  vagina.  Through  this  opening- 
accessible  tubercular  lesions  can  be  treated  b}-  the  use  of  the  sharp  spoon 
and  the  direct  application  of  iodoform.  The  parts  below  this  opening- 
should  be  protected  against  the  irritating-  effect  of  urine  b}-  applications 
of  vaselin  or  lanolin  containing  one  of  the  milder  antiseptic  remedies. 
After  the  fistulous  opening  has  been  established  the  bladder  can  be 
irrigated  with  antiseptic  solutions,  or  a  mixture  containing  iodoform, 
through  the  urethra. 

In  the  male  the  same  objects  are  attained  most  efficientl}'  b}'  making 
a  suprapubic  cystotoni}',  as  through  a  perineal  incision  the  direct  treat- 
ment of  tubercular  lesions  is  impossible.  The  fistulous  communication 
should  be  made  complete  by  suturing  the  margins  of  the  visceral  wound 
to  skin-flaps  taken  from  each  side  of  the  external  incision, — a  method  first 
suggested  by  Morris,  of  New  York.  B}'  lining  the  margins  of  the 
incision  with  mucous  membrane  and  skin,  the  loose  connective  tissue  in 
the  pre-vesical  space  is  protected  against  infection,  and  the  fistulous 
opening  is  rendered  permanently  patent.  At  the  time  of  operation 
visible  tubercular  ulcers  are  curetted  and  iodoformized.  The  bladder 
can  be  irrigated  subsequently  through  the  urethra  or  through  the 
fistulous  opening. 

In  a  case  of  advanced  primary  tuberculosis  of  the  bladder  where  I 
pursued  this  method  of  treatment  the  operation  afforded  marked  relief, 
but  appeared  to  have  no  influence  in  retarding  a  fatal  termination,  as  the 
disease  had  already  extended  to  the  kidnej^s.  The  patient  lived  for 
nearly  two  months  in  comparative  comfort,  the  principal  complaint  made 
being  the  moisture  caused  b}-  the  constant  escape  of  urine  through  the 
artificial  urethra. 

A  case  is  described  by  Battle  in  which  recover}'  followed  curetting 
through  a  suprapubic  incision,  after  the  failure  of  less  formidable  means. 
The  patient  was  a  girl  aged  20  years.     The  operation  was  performed 


548  PRINCIPLES   OF   SURGERY. 

July  29,  1889.     The  patient  was  discharged  September  20th,  and  April 
8,  1890,  was  in  good  health  and  working  at  her  trade. 

In  cases  where  the  disease  in  the  bladder  is  circumscribed,  and  the 
organ  is  opened  early,  the  treatment  might,  occasionally  at  least,  result 
in  a  permanent  cure,  if  the  infected  tissues  can  be  completely  removed 
b}^  curetting  or  destroyed  by  the  actual  cautery  through  the  incision 
at  the  time  of  operation.  In  such  favorable  cases  the  opening  should 
not  be  allowed  to  close  until  the  surgeon  can  satisfj^  himself  that  the 
ulcers  have  completely  healed,  and  that  no  new  centres  of  infection  are 
present. 


CHAPTER  XXII. 

Actinomycosis  Hominis. 

Actinomycosis  is  a  form  of  chronic  inflammation  caused  by  the 
presence  of  actinomyces  or  ray-fungus.  Until  quite  recently  this  disease 
was  included  among  the  malignant  tumors,  and  we  have  reason  to 
believe  that,  in  many  of  the  reported  cases  after  operations  for  sarcoma,  the 
disease  for  wliich  the  operations  were  done  was  not  sarcoma,  but  actino- 
m3'cosis.  Before  degeneration  of  the  inflammatory  product  has  taken 
place  actinomycosis  resembles  a  tumor  more  closely  than  any  other 
inflammator}'  swelling.  The  swelling  is  composed  largely  of  granulation 
tissue,  which,  on  examination  under  the  microscope,  presents  a  histo- 
logical structure  that,  in  the  absence  of  other  evidences,  it  would  be 
difficult  or  impossible  to  differentiate  from  a  round-celled  sarcoma.  The 
presence  of  the  specific  fungus  in  the  granulation  tissue  settles  the 
diagnosis. 

history  of  the  disease. 

The  disease,  as  occurring  in  cattle,  was  first  described  by  Bollinger, 
in  1877.  as  a  condition  in  which  sarcoma-like  tumors  were  met  with, 
associated  with  a  peculiar  growth  which,  from  its  structure,  was  named 
'■'■  Strahlen  pilz^''  (ray -fungus),  or  actinomj'ces.  James  Israel  was  the 
first  to  recognize  the  disease  in  man,  but  it  was  not  generally  understood 
until  the  appearance  of  the  classical  work  of  Ponfick  ("  Die  Aktino- 
mykose  des  Menschen,''  Berlin)  in  1882.  Numerous  articles  on  this 
subject  have  since  appeared  in  the  current  medical  literature,  so  that 
Partsch,  in  1888,  mentioned  in  his  monograph  seventj'^-five  references, 
with  a  supplemental  list  of  thirty-three  names  furnished  b}-  Schuchardt. 
Since  the  publication  of  Israel's  case  numerous  cases  have  been  reported 
by  different  observers,  representing  Germany,  England,  Belgium,  Switzer- 
land, Russia,  Austria,  France,  and  America  ;  so  that  Partsch  in  his  paper 
estimates  the  Avhole  number  up  to  that  time  at  not  less  than  one  hundred. 
While  most  of  the  articles  in  medical  journals  contain  only  a  descrip- 
tion of  isolated  cases,  it  appears  to  have  been  the  good  fortune  of  some 
of  the  writers  on  this  subject  to  meet  with  a  number  of  cases  in  a  com- 
parativel3'  short  time.  Thus,  Hochenegg  reports  7  cases  that  came 
under  his  observation,  and  Moosbriigger  has  increased  the  list  of 
published  cases  by   10  well-authenticated  and  carefully  recorded  cases. 

(549) 


550 


PRINCIPLES   OF   SURGERY. 


Rotter  observed  13  cases  in  two  years.  Albert  has  seen  not  less  than 
38  cases  of  actinomycosis  in  man  within  the  past  few  j^ears  ;  of  these 
8  have  come  under  his  observation  during  the  last  two  years.  These 
eases  have  come  mostl}'  from  Vienna  and  its  vicinitj'. 


DESCRIPTION    OF    FUNGUS. 

The  ray-fungus,  or  actinomyces,  is  not,  strictly  speaking,  a  microbe, 
as  it  is  large  enough  to  be  seen  with  the  naked  eye ;  but  its  identity  can 
only  be  ascertained  from  its  characteristic  structure,  which  I'equires  the 
use  of  the  microscope.     Bollinger  described  as  peculiar  to  this  disease 

certain  yellow  bodies,  visible  to  the 
naked  eye,  always  found  in  the  pus 
of  actinomycotic  abscesses  and  in 
the  granulation  tissue  before  suppu- 
ration had  occurred.  Microscopically, 
they  were  found  to  consist  of  threads 
similar  to  the  ordinary  m^'celium, 
which  terminated  in  bulbous  ends. 

The  threads  radiate  from  the 
centre,  and  their  clubbed  extremities 
impart  to  the  fungus  the  character- 
istic ra3'-like  appearance.  Sometimes 
but  one  of  these  bulbs  is  connected 
with  a  thread ;  at  other  times  there 
may  be  several.  In  some  specimens 
one  of  the  rays  projects  far  be3'ond 
the  others  and  terminates  b}-  several 
bulbous  ends,  as  is  shown  in  Fig.  99. 
In  man  the  actinomj-ces  occurs  as 
a  small,  globular  mass,  commonly 
about  the  size  of  a  millet-seed,  usu- 
alh'  of  a  pale-yellow  color, but  at  times 
white,  brown,  green,  or  speckled,  the  color  being  influenced  by  age  and 
the  consecutive  pathological  conditions  by  which  it  ma}-  be  surrounded. 
In  man  the  clubbed  bodies  are  often  absent,  and  the  growth  then  consists 
of  the  radiating  filaments  alone.  The  rays,  when  immersed  in  water  or 
in  a  weak  solution  of  chloride  of  sodium,  become  enormousl}-  swollen  and 
lose  their  shape ;  while  thej'  effectuall}'  resist  the  action  of  acids,  ether, 
and  chloroform. 

Staining. — For  staining  the  actinomyces,  Weigert  uses  Wedl's 
orseille  ;  Mnrehand,eosin  ;  Dunker  and  Magnussen,  cochineal-red  ;  Moos- 
briigger,  haematoxylon-alum  ;  and  Partsch,in  section-staining,  has  had  the 


Fig.  99.— Ray-Fungus,  with  One  of 
THE  Rays  More  Projecting  and 
Branching.    (Ponfick.) 


DESCRIPTION    OF    FUNGUS.  551 

best  results  with  Gram's  method.  Recently,  Babes  has  made  beautiful 
diy  preparations  by  using  a  2-per-cent.  solution  of  safranin  in  aniline-oil, 
followed  b}'  treatment  with  iodide  of  potassium. 

0.  Israel  has  found  that  a  solution  of  orcein  in  acetic  acid  stains  the 
rays  a  Bordeaux-red,  while  the  filaments,  if  decolorization  is  not  carried 
too  far,  present  a  blue  tinge.  Baranski  uses  picro-carmine  for  staining 
fresli  preparations  of  actinomyces  bovis.  A  small  amount  of  the  contents 
of  a  yellow  nodule,  or  pus  from  the  part,  is  spread  in  a  thin  layer  on  a 
cover-glass  and  dried  in  the  air.  The  cover  is  then  passed  three  times 
through  the  flame  of  an  alcohol-lamp,  care  being  taken  not  to  overheat 
the  preparation.  It  is  then  floated  in  the  picro-carmine  solution,  or  a 
few  drops  of  the  staining  fluid  are  placed  on  the  cover.  The  whole 
process  of  staining  is  completed  in  two  or  three  minutes.  The  cover  is 
then  carefull}-  washed  by  agitating  it  in  distilled  water  and  alcohol,  and 
examined  in  water  and  glycerin.  The  fungus  takes  a  3'ellow  color,  while 
the  remaining  fitructure  a[)pears  red. 

Cultivation  Experiments. — It  has  been  found  extremely  difficult  to 
cultivate  the  actinomyces  outside  of  the  bod}',  probabl}-  on  account  of 
the  usual  culture  media  not  being  well  adapted  for  its  growth.  Tiie  first 
successful  experiments  were  made  in  1886  by  Bostrdm,  of  Giessen,  upon 
plates  of  coagulated  blood-serum  and  agar-agar,  the  fungus  attaining  its 
maturity  in  five  or  six  days,  when  it  presented  the  t3'pical  structure  of 
actinomycosis  as  found  in  man.  0.  Israel  cultivated  the  fungus  success- 
fully upon  coagulated  blood-serum.  Upon  this  medium  the  culture 
grows  very  slowly  and  the  fungus  often  undergoes  calcification.  Israel 
made  the  observation  that  water,  glycerin,  blood-serum,  and  Aveak  saline 
solutions  seriousl}-  impair  the  vitalit}-  of  the  fungus,  and  he  maintained 
that  tiie  eftect  of  these  agents  on  the  actinomyces  explains  the  failure 
of  previous  culture  and  inoculation  experiments.  If  evaporation  is  pre- 
vented, a  thin,  velvety  la^-er  forms  on  tlie  surface  of  the  blood-serum  in 
about  eight  weeks,  in  the  vicinit}'  of  which,  not  before  the  expiration  of 
fourteen  days,  cell-nodules  appear  more  in  a  downward  direction  than  on 
the  sides  of  the  inoculation  streak.  From  the  tenth  to  the  fourteenth 
day  numerous  spores  are  produced  and  a  thick  wall  of  club-shaped 
mycelia  in  typical  centrifugal  arrangement. 

At  a  meeting  of  the  Medical  Society  of  Berlin,  March  5,  1890,  M. 
Wolft'made  a  communication  in  which  he  described  culture  experiments 
with  actinomyces  which  he  made  jointly  with  James  Israel.  He  an- 
nounced that  they  had  succeeded  in  cultivating  the  fungus  in  and  upon 
coagulated  albumen  of  egg  and  agar-agar.  The  material  used  was  taken 
from  a  case  of  retromaxillary  actinomycosis  immediately  after  the 
abscess  was  incised.     With  the  yellow  granules  stab  and  streak  inocu- 


552  PRINCIPLES   OF    SURGERY. 

lations  were  made,  using  agar-agar  as  a  soil.  It  was  found  that  the 
actinomyces  is  not  a  purely  anaerobic  fungus,  as  it  grew  upon  the  sur- 
face as  well  as  in  the  depth  of  tiie  culture  soil.  The  agar  culture 
appeared  first  as  transparent  little  drops,  which,  by  confluence,  made  an 
opaque,  white  mass.  Under  the  microscope  the  culture  was  seen  to  be 
composed  of  short,  tliick  rods,  with  an  admixture  of  other  elements. 
The  egg  cultures,  on  the  other  hand,  were  made  up  of  short,  thick  rods 
besides  a  mass  of  threads,  some  of  them  twisted  in  the  shape  of  a  cork- 
screw, presenting  an  intricate  net-work  of  threads.  With  these  cultures 
successful  inoculation  experiments  were  made. 

Inoculation  Experiments. — In  1883,  James  Israel  succeeded  in  pro- 
ducing the  disease  artificially  in  a  rabbit  by  introducing  a  fragment  of 
actinomycotic  tissue  into  the  peritoneal  cavity.  Somewhat  later,  Pon- 
fick  made  successful  inoculation  experiments  in  calves  by  implantation 
of  infected  granulation  tissue  under  the  skin  into  the  abdominal  cavity 
or  directly  into  veins.  Rotter  experimented  on  calves,  pigs,  dogs, 
guinea-pigs,  and  rabbits,  and  in  only  one  instance,  a  rabbit,  did  he 
succeed  in  reproducing  the  disease.  In  this  case  a  piece  of  granulation 
tissue  the  size  of  a  bean  was  inserted  into  the  peritoneal  cavity,  and 
the  animal,  having  manifested  no  symptoms  of  disease,  was  killed  six 
months  after  the  inoculation.  On  opening  the  abdominal  cavity,  about 
twenty  nodules,  varying  in  size  from  the  head  of  a  pin  to  a  hazel-nut, 
were  found  distributed  over  a  considerable  surface  around  the  graft,  each 
of  them  showing  the  typical  histological  structure  of  actinomycosis. 
The  transplanted  piece  of  tissue  was  found  perfectly  encapsulated  in 
one  of  the  nodules  the  size  of  a  bean.  As  the  fungus  was  found  in 
all  the  nodules,  it  is  only  reasonable  to  conclude  that  the  disease  spread 
from  the  original  focus  b}^  migration  of  some  of  the  new  fungi,  which, 
at  their  respective  points  of  localization,  established  independent  centres 
of  infection  and  tissue  proliferation.  While  the  actinom3rces  in  the  new 
nodules  presented  a  perfect  structure,  and  could  be  readily  stained,  the 
transplanted  fungus  in  the  graft  had  lost  its  structure,  and  could  no 
longer  be  stained.  The  first  successful  inoculation  experiments  with 
pure  cultures  were  made  by  Wolff  and  James  Israel.  Three  rabbits 
were  inoculated  by  injecting  a  pure  culture  into  the  peritoneal  cavity. 
The  post-mortem  showed  numerous  nodules  upon  the  parietal  perito- 
neum, the  omentum,  and  between  the  intestinal  coils.  The  nodules  varied 
in  size  from  the  head  of  a  pin  to  that  of  a  hazel-nut,  and  each  of 
them  was  surrounded  by  a  fibrous  capsule.  The  interior  of  each  nodule 
was  composed  of  a  yellow  mass  the  consistence  of  tallow.  Typical 
actinomyces  were  found  imbedded  in  masses  of  round  cells  in  a  state  of 
fatty  degeneration. 


SOURCES    OF    INFECTION,  553 

SOURCES  OF  INFECTION. 
As  regards  the  history  of  the  parasite  outside  the  body,  as  j^et  only 
a  few  facts  are  known.  It  is  fv/Und  in  pig-meat,  and  is  peculiarly  sus- 
ceptible to  outside  influences.  Virchow  found  the  fungus  as  a  small, 
calcareous  concretion  in  the  muscle-fibres  of  the  pig,  and  considered 
their  flesh  highly  dangerous  food  unless  well  cooked.  As  the  actino- 
myces  found  in  man  and  beast  resemble  each  other  morphologically  and 
iu  their  elfect  on  the  tissues,  as  well  as  in  their  reaction  to  chemical  sub- 
stances, it  is  evident  that  the  etiology  of  the  disease  is  similar  in  both. 
The  fungus  has  never  been  found  outside  of  the  body.  Israel  is  of  the 
opinion  that  both  man  and  animals  are  infected  from  the  same  source 
such  as  vegetables  or  water.  Jensen  traced  an  epidemic  in  Seeland  to 
the  eating  of  rye  grown  on  land  recently  reclaimed  from  the  sea ;  and 
Johne  discovered  a  fungus  closely  resembling  actinomyces  in  grains 
of  rye  stuck  in  the  tonsils  of  pigs.  That  the  ears  of  barley  or  rye  are 
sometimes  the  carriers  of  the  fungus  is  well  illustrated  by  the  case 
reported  by  Soltmann.  The  patient  was  a  boy  who  had  swallowed  an 
awn  of  barley.  The  foreign  body  lodged  in  the  pharynx,  where  it  gave 
rise  to  difficulty  in  deglutition  ;  afterward  it  perforated  the  pharyngeal 
wall, — an  accident  atteniled  by  haemorrhage, — and  later  an  actinomycotic 
phlegmon  developed  ;  it  spread  rapidly,  and  finally  opened  below  tlie 
scapula.  Through  this  opening  the  foreign  body  was  extracted.  Piana 
examined  the  tongue  of  a  cow  sutt'ering  from  a  circumscribed  actinomy- 
cosis of  this  organ,  in  which  the  disease  could  be  traced  to  a  similar 
origin, — perforation  of  the  tissues  and  infection  by  a  sharp  beard  of  an 
ear  of  barley.  Actinomycosis  has  as  yet  onlj''  been  found  amongst 
herbivorous  and  omnivorous  animals,  including  man,  and  the  frequent 
location  of  the  primary  swelling  in  the  mouth  seems  to  indicate  that  the 
fungus  gains  entrance  with  food. 

PATHOLOGY    AND    MORBID    ANATOMY. 

As  to  the  manner  in  which  the  fungus  exerts  its  pathogenic  action 
much  yet  remains  to  be  ascertained.  The  most  striking  effect  is  the 
transformation  of  mature  connective  tissue  into  embryonal  or  graiiuln- 
tion  tissue.  The  fungus  possesses  no  pyogenic  properties.  It  gives  rise 
in  the  tissues  to  a  low  grade  of  chronic  inflammation,  and  becomes 
imbedded  in  the  specific  product  of  tissue  proliferation, —  granulation 
tissue. 

The  product  of  inflammation  around  each  fungus  consists  of  granu- 
lation tissue,  which,  under  the  microscope,  might  be  easily  mistaken  for 
tubercle  or  sarcoma  tissue.  At  first  the  cells  are  round  ;  at  a  later  stage 
of  the  inflammation  epithelioid  and  giant  cells  are  formed  immediatelj^ 


00^ 


PRINCIPLES   OF    SURGERY. 


around  the  fungus.  As  the  disease  is  almost  always  attended  by  sup- 
puration at  some  time  during  its  course,  it  has  been  customary  to  ascribe 
to  the  actinomyces  pyogenic  properties.  Israel  has  always  held  that  the 
actinomyces  is  a  pus-producing  fungus,  in  opposition  to  Ponfick  and 
other  pathologists,  who  claim  that  when  suppuration  takes  place  it  is  the 
result  of  a  secondary  infection  with  pus-microbes.  As  cases  of  actino- 
mycosis have  been  recorded  in  which  the  disease  remained  stationary  in 
the  granulation  stage,  for  an  indefinite  period  of  time,  without  suppura- 
tion taking  place,  and  pus-microbes  have  been  cultivated  from  the  pus 
of  actinomycotic  abscesses,  it  appears  more  than  probable  that  suppura- 
tion occurred  independently  of  the  presence  of  the  fungus,  and  was  pro- 
duced by  the  specific  action  of  pus-microbes  on  the  granulation  tissue. 
Firket  asserts  that  the  actinomyces  does  not  appear  to  produce  coagula- 
tion necrosis,  but,  from  a  study  of 
the  earliest-formed  colonies,  he 
finds  that  the  first  effect  of  the 
fungus  is  to  induce  cellular  hyper- 
plasia. It  is  as  if  the  tissue  ele- 
ments resented  the  intrusion  of 
the  parasite, which,  however,  mostly 
gains  the  upper  hand  ;  so  that  the 
result  is  the  formation  of  granula- 
tion tissue  and,  later,  abscesses  that 
characterize  the  disease.  Suppura- 
tion takes  place  earliest  when  the 
disease  occupies  a  location  where 
secondary  infection  with  pus-mi- 
crobes is  most  liable  to  occur.  As 
a  rule,  it  may  be  stated  that,  the 
earlier  suppuration  takes  place, 
the  more  rapid  is  the  spread  of  the 
disease  and  the  graver  the  prognosis ;  while  the  absence  of  suppuration 
indicates  comparative  benignity,  and  points  in  the  direction  of  a  more 
chronic  form  of  the  affection. 

The  localized  chronic  form  of  actinomycosis  resembles,  in  its  clini- 
cal features  and  its  anatomical  locations,  more  closeh'  sarcoma  than 
an}^  other  affection,  and  is  most  frequently  mistaken  for  this  form 
of  malignant  growth.  In  such  cases  it  would  be  difficult,  if  not  im- 
possible, in  the  absence  of  the  specific  fungus,  to  make  a  differential 
diagnosis  between  it  and  round-celled  sarcoma,  even  by  a  most  careful 
microscopical  examination,  as  the  histological  structure  of  both  is  almost 
identical. 


Fig.  100.— Actinomyces.  Section  from  Ac- 
tinomycotic Swelling.  X300.  (Fluegge.) 


CLINICAL    VARIETIES.  000 

CLINICAL    VARIETIES. 

If  infection  take  place  by  fully -developed  actinomj'ces,  it  can  only 
do  so  b3-  the  fungus  gaining  entrance  into  the  tissues  through  some  loss 
of  continuity  in  the  cutaneous  or  mucous  surface  ;  any  other  method  of 
ingress  is  impossible  on  account  of  the  large  size  of  the  fungus.  In  the 
cases  in  which  no  such  primar}'  infection-atrium  could  be  found,  it  must 
be  taken  for  granted  that  the  local  lesion  had  healed  between  the  time 
infection  took  place  and  the  first  manifestations  of  the  disease,  or  that 
infection  was  caused  by  the  entrance  of  spores,  which,  from  their 
smaller  size,  could  possibly  find  their  way  into  the  tissues  through 
intact  mucous  surfaces.  In  reference  to  the  primary-  localization  of  the 
disease,  Moosbrugger  gives  the  following  statistics :  In  29  cases  the 
lower  jaw,  mouth,  and  throat  were  afiected  ;  in  9,  the  upper  jaw  and 
cheek;  in  1,  the  tongue;  in  2,  the  region  of  the  cesophagus  ;  in  11,  the 
intestines ;  in  14,  the  bronchial  tract  and  the  lungs ;  in  1  the  point  of 
entrance  could  not  be  ascertained.  Infection  ma}'  take  place  through 
any  abraded  surface  brought  in  contact  with  the  specific  cause,  and  for 
clinical  purposes  the  cases  ma}"  be  divided  into  the  following  three 
groups :  1.  Cutaneous  surface.  2.  Alimentary  canal.  3.  Respiratory 
tract. 

i.  Cutaneous  Surface. — A  number  of  well-authenticated  cases  of 
primary  actinomycosis  of  the  skin  have  been  placed  on  record.  Partsch 
describes  a  case  of  actinomycosis  developing  in  the  scar  left  after  extir- 
pation of  the  breast.  The  patient  was  a  man  aged  60  years.  In  June, 
188-t,  his  left  breast  was  removed  for  an  ulcerating  carcinoma.  As  the 
Wound  did  not  heal  by  primary  union,  and  the  process  of  cicatrization  was 
very  slow,  a  number  of  small  skin-grafts  from  a  perfectly  healthy  young 
man  were  transplanted.  The  wound  was  practically  healed  in  September. 
Two  months  later  the  cicatrix  ulcerated  and  an  abscess  discharged  itself. 
Actinomyces  were  found  in  the  pus.  The  parts  were  excised,  and  the 
progress  of  the  disease  was  apparently  arrested.  No  explanation  could 
be  made  as  to  how  the  infection  occurred.  Hochenegg  reported  a  case  of 
primary  actinomycosis  of  the  skin  in  the  left  submaxillary  region.  He 
attributed  the  disease  to  an  invasion  of  the  fungus  through  a  small 
atheroma. 

In  Kaposi's  case,  when  the  disease  was  first  noticed,  it  appeared  as 
a  red  spot,  the  size  of  a  florin,  on  the  left  pectoral  muscle,  Avhich  gradu- 
ally increased  to  the  size  of  a  walnut  and  then  gradually  flattened  down 
and  disappeared.  Meanwhile,  fresh  spots  and  lumps  appeared,  some  as 
large  as  a  pigeon's  egg.  Eleven  years  after  the  beginning  of  the  disease, 
:i  swelling  as  hirge  as  an  apple  appeared  over  the  spine  of  the  sixth  ver- 
tebra, which  gradually  extended  forward  and,  a  year  later,  formed  a  large 


556  PRINCIPLES   OF    SURGERY. 

tumor  behind  the  right  axilla.  A  3eai'  later  this  swelling  had  diminished 
in  size  to  that  of  a  pigeon's  egg,  and  then  again  inereased  in  size.  Ulcera- 
tion set  in,  exposing  a  fungous,  bleeding  surface.  At  this  time  the  entire 
trunk,  but  not  the  limbs,  was  covered  with  nodules,  spots,  and  stripes. 
The  infiltration  was  located  in  the  corium.  This  case  is  remarkable  for 
the  chronicity  of  the  disease,  the  multiple  points  of  regional  infection, 
and  the  limitation  of  secondary  infection  with  pus-microbes  to  a  few 
isolated  nodules. 

At  tlie  meeting  of  the  German  Society  of  Surgeons,  in  1889,  Leser 
reported  3  cases  of  primarx^  actinom3'Cosis  of  the  skin  that  had  come 
under  his  own  observation  in  the  course  of  a  single  year.  In  his  remarks 
on  this  subject  he  placed  special  stress  on  the  manner  in  Avhich  the 
disease  extends.  In  the  periphery  of  the  primar^^  lesion  he  found 
numerous  minute  nodules,  later  becoming  the  seat  of  destructive 
changes,  resembling  in  this  respect  the  clinical  features  of  tuberculosis 
of  the  skin.  The  extension  of  the  disease  in  the  direction  of  the  deep 
tissues  takes  place  by  the  formation  of  passages  corresponding  to  the 
size  of  a  lead-pencil ;  these  are  filled  with  3^ellowisli-gray  or  reddish-gray 
granulations,  which  attack  and  destroy  tissues,  irrespective  of  their 
anatomical  structure.     The  l^-mphatic  glands  were  always  found  intact. 

2.  Alimentary  Canal. — Tiie  frequenc}-  with  whicli  the  disease  affects 
the  mouth  mid  jaws  of  cattle  is  explained  by  the  occurrence  of  numer- 
ous points  of  injury-  caused  by  masticating  rough  food,  that  furnishes 
the  necessary  infection-atrium  through  which  the  fungus  invades  the 
tissues. 

Teeth. — In  man  infection  takes  place  fre(piently  through  carious 
teeth,  and  through  abrasions  in  the  gums  and  mucous  membrane  of  the 
mouth.  Israel  found  the  fungus  in  the  cavities  of  carious  teeth,  and 
Partsch  detected  in  the  same  localitx^  almost  pure  cultures  without  any 
manifestation  of  disease  except  chronic  peri-odontitis.  The  fungus 
occurs  here  often  side  b}^  side  with  leptothrix. 

Tongue. — Hochenegg  saw  a  case  of  actinom3'cosis  of  the  tongue 
caused  by  an  infected  carious  tooth.  Tiie  swelling  was  the  size  of  a 
cherry,  located  near  the  apex  of  the  organ.  The  affection  had  existed 
for  two  months.  The  growth  was  excised,  and  on  examination  was 
found  to  consist  of  granulation  tissue,  with  a  central  yellow  mass  the  size 
of  a  millet-seed.  Besides  this  case  only  3  cases  of  actinomycosis  of  the 
tongue  are  on  record, — 1  primary,  1  secondary  to  disease  of  the  jaw, 
and  1  metastatic. 

Jaws. — Tliat  carious  teeth  furnish  a  frequent  infection-atrium  in 
maxillarj'  actinomycosis  is  well  known,  and  in  many  instances  the 
disease  in  its  early  stages  has  been  mistaken  for  an  ordinary  dental 


CLINICAL    VARIETIES.  557 

affection,  and  patients  have  often  songht  relief  at  the  hands  of  a  dentist. 
The  lower  jaw  is  most  frequenth'  affected,  the  growth  being  connected 
with  the  bone  or  situated  close  to  it,  or  it  has  already- extended  to  the 
submental  or  submaxillary  region.  The  disease  often  pursues  a  chronic 
course,  closel}'  simulating  periosteal  sarcoma,  until  it  reaches  the  loose 
tissues  of  the  neck,  when  rapid  extension  takes  place,  in  a  downward 
direction,  along  the  subcutaneous  connective  tissue  and  the  inter- 
muscular septa.  Israel  refers  to  a  case  in  which  the  actinomycotic 
swelling  in  the  submaxillar}'  region  extended,  in  five  months  (August 
to  December),  to  the  level  of  the  thyroid  cartilage.  When  the  disease  is 
primaril}^  located  in  the  upper  jaw,  which,  however,  occurs  onl^'in  excep- 
tional cases,  it  tends  to  invade  rapidly  the  adjacent  soft  parts,  and  even 
to  implicate  the  base  of  the  skull  and  the  brain.  The  prognosis  is 
always  more  serious  when  the  disease  affects  the  upper  than  the  lower 
jaw,  as  the  tendency  here  to  invade  the  deep  structure  is  much 
greater.  Two  cases  of  actinomycosis  in  man  have  come  under  mj^ 
observation,  and  as  both  of  them  originated  in  the  mouth,  and  repre- 
sent, from  a  prognostic  point  of  view,  two  distinct  classes,  I  will  describe 
them  briefly. 

The  first  patient  was  a  man  30  years  of  age,  German  bj'  birth,  and 
a  soda-water  manufacturer  b}-  occupation.  His  business  required  him  to 
make  frequent  trips  into  the  countr}-  bj-  team.  He  had  no  recollection 
of  having  come  in  contact  with  cattle  suffering  from  "  swelled  head"  or 
"lumpy  jaw."  During  the  winter  of  1886  he  suffered  from  what  he 
supposed  was  an  ordinarj^  cold  ;  the  right  side  of  the  lower  jaw  was 
swollen  and  painful.  As  one  of  the  molar  teeth  showed  evidences  of 
deca}'  and  had  become  loose,  it  was  extracted.  The  pain  and  swelling, 
however,  did  not  improve,  and  the  attending  physician  extracted  all  of 
the  molar  teeth  of  the  lower  jaw  on  that  side.  At  this  time  a  fungous 
mass  commenced  to  appear  over  the  surface  of  the  edentulous  bone. 
The  cheek  on  the  affected  side  was  also  greatl}'  swollen.  The  patient 
was  admitted  into  the  Milwaukee  Hospital  about  six  months  after  the 
first  SA'mptoms  had  appeared.  At  this  time  the  lower  jaw,  in  the  mouth, 
presented  a  fungous  mass  extending  from  the  angle  of  the  bone  to  the 
first  bicuspid ;  the  swelling  extended  as  far  as  the  tonsil.  The  cheek 
was  enormoush-  swollen  from  the  angle  of  the  mouth  to  the  lower 
margin  of  the  parotid  gland.  The  skin  over  the  swollen  part  presented 
a  pale,  gloss}'  appearance,  and  the  superficial  veins  were  considerably 
dilated.  Around  the  margin  of  the  swelling  no  distinct  border-line 
could  be  felt,  the  infiltrated  parts  fading  graduall}"  into  the  health}'  sur- 
rounding tissues.  Free  suppuration  from  the  surface  of  the  fungous 
granulations,  and  a  number  of  small  abscesses  had  dischnrged  themselves 


558  PRINCIPLES   OF    SURGERY. 

into  the  cavity  of  the  month.  As  some  donbt  existed  as  to  the  char- 
acter of  the  inflammation,  carefnl  and  repeated  examinations  were  made 
of  the  pus  removed  from  the  small  abscess-cavities,  and  on  several  occa- 
sions fragments  of  actinomyces  were  found.  The  discovery  of  the 
specific  cause  of  the  inflammation  cleared  up  the  diagnosis  and  furnished 
an  urgent  indication  for  operative  treatment.  An  incision  was  made 
along  the  lower  border  of  the  jaw  from  just  below  the  articulation  to 
near  the  symph3-sis,  and,  after  arresting  .'ill  ha?morrhage,  it  was  carried 
into  the  cavit}'  of  the  mouth.  The  alveolar  processes  of  the  jaw  were 
affected,  and  were  removed  with  chisel  and  cutting-foi'ceps.  Wherever 
the  periosteum  showed  signs  of  infiltration  it  was  carefully  scra[)ed 
awa}'-,  and  finally  the  whole  bone  surface  was  thoroughly  cauterized.  The 
infiltrated  soft  tissues  were  dissected  out  with  knife  and  scissors ;  the 
disease  was  found  to  hnve  extended  as  far  as  tlie  tonsil.  The  bottom  of 
the  wound  was  iodoformized  and  packed  with  iodoform  gauze,  while  the 
external  wound  was  sutured.  The  entire  external  wound  healed  In- 
primary  union,  and  the  cavity  in  tlie  month  closed  slowly  by  granula- 
tion. The  patient's  general  health  continued  to  improve  rapidly,  until 
six  weeks  after  the  operation,  when  tlie  neck  below  the  scar  became 
swollen,  followed  in  a  short  time  by  the  formation  of  abscesses  reaching 
from  the  angle  of  the  jaw  to  the  clavicle,  and  posteriorly  as  far  as  the 
spine  of  the  scapula.  Numerous  openings  were  made  and  efficient 
drainage  established,  but  suppuration  continued  unabated,  and  the 
patient  became  extremely  emaciated.  The  suppurative  inflammation 
extended,  and  four  months  after  the  first  operation  the  patient  died  ;  the 
symptoms  during  the  last  days  of  life  pointed  to  a  hypostatic  pneumo- 
nia. Actinomyces  were  continuous!}-  found  in  the  pus  during  the  entire 
course  of  the  disease.  I  believe  that  the  recurrence  of  the  disease  was 
due  to  imperfect  removal  of  infected  tissues  in  the  posterior  and  lower 
portion  of  the  pharynx. 

The  second  case  came  under  m}'^  care  during  the  summer  of  1887. 
The  patient  was  a  young  man,  employed  on  a  farm.  About  five  months 
before  he  was  admitted  into  the  Milwaukee  Hospital  he  had  a  number  of 
teeth  extracted  from  the  right  upper  jaw,  under  the  belief  that  the  teeth, 
some  of  which  were  decayed,  were  the  cause  of  the  pain  and  swelling  in 
tliat  region.  The  ph3-sician  in  attendance  diagnosed  sarcoma  of  the 
upper  jaw,  and  sent  the  case  to  me  for  operation.  On  my  first  examina- 
tion, I  found  a  swelling  involving  the  right  side  of  the  face,  extending 
from  the  zygomatic  arch  to  near  the  lower  border  of  the  lower  jar,  in- 
volving the  deep  tissues,  and  connected  with  the  alveolar  processes  of 
the  posterior  portion  of  the  upper  jaw.  The  swelling  was  firm  and  with- 
out well-defined  margins.     No  evidences   of  suppuration.     The  historj- 


CLINICAL   VARIETIES.  559 

of  the  case,  and  particularly  the  location,  extent,  and  physical  properties 
of  the  swelling,  led  me  to  the  opinion  that  it  was  the  result  of  actinomj-- 
cotic  infection.  All  infected  tissue  was  thoroughly  excised  tlirough  a 
large  external  incision,  the  jaw-bone  scraped  and  cauterized.  The  entire 
thickness  of  the  cheek,  with  the  exception  of  the  skin  and  superficial 
fascia,  appeared  to  be  transformed  into  granulation  tissue.  In  the  granu- 
lations numerous  minute  yellowish-gray  bodies  were  found,  which,  under 
tlie  microscope,  showed  the  tjq^ical  structure  of  the  ray-fungus.  The 
mj'^celia  were  not  so  bulbous  as  we  find  them  pictured  in  the  books,  but 
the  distal  extremity  appeared  to  be  surrounded  I)}-  dust-like  bodies,  pre- 
senting the  appearance  of  a  small  brush.  These  minute  granules  I  re- 
garded as  spores.  In  the  first  case,  in  which  suppuration  had  taken 
place,  I  never  succeeded  in  finding  the  actinom3-ces  perfect  and  com- 
plete; in  the  second  case  the  granulation  tissue  had  not  been  destroyed 
by  suppuration,  and  the  fungus  was  found  in  a  perfect  condition  and  in 
a  state  of  fructification.  These  cases  present  a  striking  contrast,  both  in 
regard  to  the  local  condition  and  the  ultimate  termination.  In  the  first 
case  secondary  infection  with  pus-microbes  had  already  taken  place,  and 
the  phlegmonous  inflammation  that  followed  this  occurrence  prepared 
the  tissues  again  for  the  diffusion  of  the  actinom3-cotic  process;  while 
in  the  second  case  the  inflammatory  process  had  not  passed  beyond  the 
granulating  stage,  and  the  boundar3'-line  between  health}^  and  diseased 
tissue  was  also  more  distinctly  marked, — a  most  important  factor  in  the 
operative  treatment.  The  first  patient  died  from  recurrence  of  the  disease 
in  the  vicinit}'  of  the  operation  wound  and  its  extension  to  the  neck  and 
chest;  while  in  the  second  case  the  wound  healed,  and  the  patient  has 
remained  in  i^erfect  health  since. 

3.  intestinal  Canal. — In  primary  intestinal  actinomycosis  the  disease 
is  caused  b}'  ingress  of  the  fungus  with  food  or  water,  and  its  implanta- 
tion upon  the  mucous  surface.  At  the  point  of  implantation  the  fungus 
multiplies,  and  by  its  growth  invades  the  submucous  tissue,  which 
becomes  the  seat  of  active  tissue  proliferation.  Arrest  and  implantation 
of  the  actinomyces  are  determined  by  antecedent  pathological  changes. 
Chiari  has  given  an  excellent  account  of  the  pathological  condition  found 
in  a  case  of  intestinal  actinomycosis  that  came  under  his  observation. 
Tlie  patient  was  a  man  36  years  of  age,  who  during  life  presented,  as 
the  most  prominent  clinical  feature,  progressive  marasmus.  At  the 
necropsy  chronic  tuberculosis  in  the  apices  of  the  lungs  and  a  few 
tubercular  ulcerations  in  the  lower  portion  of  the  ileum  were  found.  The 
large  intestine  presented  a  verj'  remarkable  appearance,  the  mucous  mem- 
brane of  which,  except  the  caecum  and  ascending  colon,  was  covered  with 
whitish  deposits,  forming  round  and   oblong  patches,  some  of  them   1 


560  PRINCIPLES    OF    SURGERY. 

cubic  cenliiuetre  in  diameter  and  5  millimetres  in  thickness.  In  some  of 
these  patches  could  be  seen  minute  yellowish-brown  and  yellowish-green 
granules.  The  patches  were  firmly  adherent,  and  when  removed  left  a 
loss  of  substance  in  the  mucous  membrane.  The  mucous  membrane 
throughout  was  in  a  state  of  catarrhal  inflammation.  On  microscopical 
examination  the  grannies  proved  to  be  actinomyces.  The  mycelium 
had  penetrated  into  the  tubular  glands  and  showed  calcified,  club-shaped 
conidia.  The  calcification  of  the  club-shaped  extremities  had  undoubt- 
ed\y  prevented  deeper  penetration  of  the  fungus.  Hochenegg  presented 
a  case  of  actinomj-cosis  to  the  Medical  Society'  in  Vienna  in  a  man  43 
years  of  age,  who  had  sustained  an  injury  of  the  abdomen  nine  months 
l)reviousl3',  and  had  since  that  time  noticed  a  painful  swelling  at  the  seat 
of  injury.  In  the  region  of  the  umbilicus  a  fistulous  opening  formed, 
which  continued  to  discharge  a  thin  secretion,  in  which  actinomj^ces  were 
constantly  found.  The  patient  was  very  much  emaciated  and  many  of 
the  teeth  carious.  There  was  no  swelling  about  the  jaws  or  neck.  Ex- 
amination of  the  organs  of  the  chest  and  the  sputum  revealed  no  addi- 
tional diagnostic  information.  The  author  expressed  the  opinion  that 
the  inflammatory  swelling  caused  by  the  contusion  furnished  the  necessary 
conditions  for  the  localization  of  actinomyces  from  the  intestinal  canal. 

Zemann  reports  5  cases  of  actinom^'cosis  of  the  abdomen.  In  4 
of  them  the  disease  commenced  with  sharp,  lancinating  pains  in  the 
abdomen,  and  during  their  course  presented  the  clinical  picture  of 
chronic  peritonitis.  Swellings  could  be  found  in  one  or  more  places  in 
the  anterior  abdominal  wall,  and  the  abscesses  were  either  incised  or 
opened  spontaneously,  and  in  3  cases  thej-  communicated  with  the  in- 
testinal canal.  The  first  case  was  a  woman,  30  years  of  age,  who  had  a 
fistulous  opening  in  the  anterior  abdominal  wall  which  communicated 
with  a  swelling  in  the  left  parametrium.  The  patient  stated  that  this 
swelling  appeared  soon  after  her  last  childbed.  A  constant  discharge  of 
yellowish-red  pus  was  maintained,  in  which,  under  the  microscope,  nu- 
merous actinom3'ces  could  be  seen.  The  patient  died  of  exhaustion,  and 
at  the  post-mortem  chronic  para-  and  peri-  metritis  were  found,  with  ex- 
tensive pus-cavities  that  communicated  with  the  rectum  and  1)ladder. 
The  second  case  occurred  in  a  person  18  years  of  age,  who,  during  life, 
had  suffered  from  a  large  abscess  in  the  abdominal  cavit3',  under  the 
right  lobe  of  the  liver,  which  communicated  with  the  intestinal  canal, 
and  had  led  to  numerous  fistulous  openings  in  the  anterior  abdominal 
wall. 

At  the  necropsy  a  loop  of  the  ileum  was  found  perforated  and  in 
communication  with  the  abscess-cavit}-.  The  pus  contained  numerous 
actinomyces.     In  the  third  case  the  diagnosis  was  made  post-mortem  b\'' 


CLINICAL    VARIETIES.  661 

the  discovery  of  actinomyces  in  the  pus.  The  disease  was  located  in 
the  lower  portion  of  the  ileum  and  caecum,  where  it  had  caused  suppura- 
tion and  numerous  adhesions.  A  most  remarkable  and  interesting- 
histor}'  is  connected  with  tlie  fourth  case.  A  robust,  well-nourished 
woman,  40  3'ears  of  age,  was  attacked  quite  suddenly  with  pain  in  the 
stomach,  high  temperature,  diarrhoea,  and  vomiting,  followed  by  cerebral 
symptoms  and  death.  At  the  necropsy  the  riglit  Fallopian  tube  was 
found  transformed  into  a  large  abscess,  both  extremities  of  the  tube 
closed,  and  walls  of  sac  lined  with  granulations  containing  actinomj'ces. 
The  fifth  patient  was  50  years  of  age,  and  had  suttered  for  a  long  time 
from  lancinating  pain  in  the  abdomen  ;  a  fistulous  opening  formed  in  tlie 
umbilical  region  and  discharged  a  thin,  3'ellowish-green  pus.  The  post- 
mortem showed  actinomj'cosis  of  the  peritoneum,  small  intestine,  left 
ovarj-,  and  liver  ;  large  abscess  among  the  intestinal  coils  ;  perforation  of 
small  intestine  and  bladder.  In  the  upper  part  of  the  small  intestine 
small  pigmented  cicatrices  were  found.  In  all  of  the  above  cases  the 
microscopical  examination  revealed  the  presence  of  actinomyces  in  the 
granulation  tissue  as  well  as  in  the  pus  of  the  abscess-caAities.  In  a 
case  of  intestinal  actinom3'cosis  reported  by  Langhans,  the  disease 
started  evidently  from  the  appendix  vermiformis,  4  centimetres  in 
length,  the  end  of  which  appeared  as  if  transversel}'  cut  in  an  abscess- 
cavity  the  size  of  a  walnut.  The  abscess  was  on  the  right  side  of  the 
bladder,  and  so  deep  in  the  pelvis  that  during  life  it  could  not  be  located. 
The  abscess  pursued  a  chronic  course,  and  the  walls  were  well  defined ; 
no  signs  of  chronic  or  acute  peritonitis.  Furthermoi'e,  the  mucous 
membrane  of  the  appendix  was  studded  with  cicatrices,  and  presented  a 
slate  color.  The  principal  seat  of  the  actinomycotic  process  was  in  the 
liver.  In  a  second  case  reported  by  the  same  author  tlie  clinical  course 
of  the  disease  resembled  perityt)hlitic  abscess.  The  necropsy  showed 
perforation  of  the  caecum  and  ascending  colon.  No  cicatrices  in  the 
mucous  membrane  or  surrounding  tissues.  In  all  probability^,  the 
perforations  occurred  from  without  inward. 

Luening  and  Hamm  have  recently  reported,  with  interesting  details, 
a  case  of  primary  actinomycosis  of  the  colon  with  metastatic  deposits 
in  the  liver.  The  patient  was  a  man  28  years  of  age,  who,  in  1880, 
suffered  from  an  acute  abdominal  affection,  which  at  the  time  was 
diagnosed  as  typhlitis.  Four  years  later  a  second  attack  occurred, 
attended  b}'  symptoms  of  intestinal  obstruction.  Patient  was  very  ill 
for  eight  days,  when  the  symptoms  of  obstruction  subsided,  and  he 
made  a  slow  recovery.  During  the  3-ear  1887  he  had  a  third  attack, 
attended  by  high  fever  and  absolute  constipation  for  eight  to  ten  daj'S. 
During  the  month  of  December  of  the  same  3'ear  he  had  another  but  less 


562  PRINCIPLES   OF   SURGERY. 

severe  attack,  and  at  this  time  a  hard  swelling  made  its  appearance  in 
the  right  side  of  the  abdomen.  From  this  time  until  he  was  admitted 
into  the  liospital,  April  5,  1888,  he  was  confined  to  bed.  The  patient 
was  at  tliis  time  greatly  emaciated,  with  a  temperature  of  from  38.4°  C. 
to  39.8°  C.  Swelling  tlie  size  of  a  fist  in  the  right  side  of  the  abdomen, 
half-way  between  umbilicus  and  anterior  superior  spine  of  the  ileum. 
Externally  this  swelling  presented  redness  and  oidema.  Fluctuation 
indistinct.  Deep  palpation  showed  tliat  the  swelling  extended  to  right 
h3'pochondrium  ;  abdomen  not  tympanitic.  Swelling  painful  and  tender, 
pain  extending  to  spermatic  cord  and  testicle  on  same  side.  A  few  da3^s 
later  abscess  was  incised,  and  nearly  a  quart  of  brownish  pus,  having  a 
fsecal  odor,  escaped.  Digital  exploration  revealed  an  irregular  cavity, 
whose  walls  at  some  points  were  plainly-  lined  with  intestinal  coils. 
Disinfection  and  drainage.  As  the  symptoms  did  not  improve  materiall}', 
the  abscess-cavity  was  again  scraped  out  and  disinfected  four  weeks 
later.  After  the  second  operation  it  was  noticed  that  the  pus  contained 
yellow  granules,  which,  under  the  microscope,  were  shown  to  be  actino- 
myces.  The  abscess  was  incised  a  third  time,  but  the  patient  kept  losing- 
ground,  and  died  October  9th.  The  autopsy  revealed  primarj'^  actino- 
m^'cosis  of  the  ascending  colon,  with  multiple  fistulous  perforations.  A 
metastatic  actinom^'cotic  abscess  of  the  liver  had  perforated  into  the 
hepatic  vein,  resulting  in  multiple  metastases  in  the  lungs.  The  cases 
of  intestinal  actinomj-cosis  reported  above  warrant  the  opinion  that  the 
mucous  membrane  of  the  intestinal  canal  is  frequentl}^  the  seat  of 
primar}'  localization  of  the  actinomyces,  thus  corroborating  the  state- 
ments of  Johne  in  reference  to  this  disease  in  animals. 

BRONCHIAL   TUBES   AND    LUNGS. 

If  an  actinoiuyces  should  be  inlialed  with  the  inspired  air,  and 
should  become  implanted  upon  the  bronchial  mucous  membrane,  and 
find  favorable  conditions  for  its  growth,  the  granule  will  become  sur- 
rounded by  new  cells  derived  from  the  pre-existing  epithelial  cells,  and 
thus  become  the  centre  of  a  minute  granuloma. 

By  multi[)lieation  of  the  actinomyces  new  nodules  are  produced, 
around  each  of  which  the  pre-existing  tissue  is  transformed  into 
embr3'onal  tissue,  wiiicli  in  time  is  destroyed,  resulting  in  suppuration 
and  loss  of  tissue.  Israel  reported  a  case  of  actinom3'Cotic  abscess  of 
the  lung  caused  bj?^  the  entrance  of  an  infected  tooth  into  the  air- 
passages.  In  this  instance  the  fungus  was  conveyed  into  the  bronchial 
tube  with  the  carious  tooth,  and  the  infected  foreign  body  became  the 
centre  of  the  specific  inflammation. 

Cases  of  primary  actinomj-cosis  of  the  lungs,  however,  have  been 


BRONCHIAL   TUBES   ANt>   LUNGS. 


563 


observed  where  no  such  direct  carrier  of  the  contagiiim  coukl  be  foiiiul, 
and  in  which  infection  must  have  occurred  by  the  direct  inhalation  of 
the  fungus  or  its  spores  with  the  inspired  air.  Szcnas}-  found,  in  the 
case  of  the  wife  of  a  butcher,  who  had  suffered  for  nine  3'ears  from 
severe  pain  in  the  right  side  of  the  chest,  latterly  attended  b}'  a  severe 
cough,  in  the  right  manunarv  region,  a  fluctuating  swelling,  the  size  of  a 
hen's  egg,  covered  with  normal  skin.  On  the  outer  side  of  this  swelling, 
in  the  intercostal  space  between  the  tliird  and  fourth  ribs,  another  swell- 
ing existed,  double  in  size  and  elongated  in  shape,  and  with  indistinct 
margins.  This  latter  swelling  has  been  noticed  for  nine  j'ears,  and  was 
tender  to  the  touch.  Auscultation  OA'er  the  fourth  and  fifth  intercostal 
spaces  on  the  healthy  side  revealed  bronchial  breathing  and  diffuse 
bronchial  rales.  Temperature,  38.4°  C.  (101.1°  F.).  The  urine  contained 
a  trace  of  albumen.    By  aspiration  150  cubic  centimetres  of  thick,  j-ellow 


Fig.  101  .—Actinomyces  from  Lttng  of  Cow.    Fungits  in  the  Centre  of 
Inflammatory  Product.    X  350.    (Marchand.) 

A,  normal  epithelial  cells  of  bronchus  attached  to  connective  tissue ;  B,  large  epithelioid  cells ;  C,  leucocytes. 

pus  were  removed,  and  contained  colonies  of  actinomyces.  Actinom3'ces 
were  also  found  in  the  sputum.  The  patient  had  carious  teeth,  but  no 
signs  of  actinomycosis  could  be  detected  in  the  mouth. 

Canali  relates  the  clinical  history  of  a  girl,  15  years  of  age,  who 
had  suffered  for  eight  years  from  a  cough,  attended  by  a  scant}',  fetid 
expectoration.  Inspection  and  percussion  j-ielded  only  negative  results. 
Auscultator}'  symptoms  pointed  to  a  diffuse  catarrh.  Under  the  micro- 
scope the  sputum  was  seen  to  contain  pus-corpuscles,  epithelial  cells,  and 
numerous  actinomj'ces.  No  primary-  source  of  infection  could  be  found 
in  the  mouth,  phar^mx,  or  nose. 

Moosbriigger  interprets  the  mechanism  of  the  ingress  of  actinom3'ces 
by  assuming  that  the  fungus  enters  the  In'onchial  tubes  during  inspira- 
tion, and  becomes  at  first  deposited  upon  the  mucous  membrane,  where 
its  pi'esence  and  growth  cause  a  destruction  of  the  epithelial  cells,  when 
it  reaches  the  submucous  and  peri-bronchial  tissues,  in  which  a  nodule 


564  PRINCIPLES   OF    SURGERY. 

of  granulation  tissue  is  prodnc(Ml  that  by  pressure  induces  degenerative 
changes  and  gradual  destruction  of  the  broncliitvl  wall  for  further  infec- 
tion. He  believes  that  the  pori-l)ronchial  lyni[)hatic  vessels  and  glands 
take  an  active  part  in  tlie  local  diffusion  of  the  process,  as  they  furnish 
an  avenue  for  the  dissemination  of  the  fungus  or  its  spores.  He  claims 
the  existence  of  an  actinomycotic  lymphangitis,  but  confesses  that  he 
has  never  seen  the  fungus  inside  of  lymphatic  vessels.  As  soon  as  the 
fungus  reaches  the  pulmonary  tissues,  it  gives  rise  to  parenchymatous 
inflammation,  whose  first  protluct  is  always  granulation  tissue,  which,  at 
a  later  stage,  and  under  the  influence  of  a  secondary  infection  with  pus- 
microbes,  undergoes  transformation  into  pus-corpuscles  and  the  formation 
of  abscesses. 

ACTINOMYCOSIS   OF   BRAIN. 

Quite  recently,  Bollinger  placed  on  record  the  first  case  of  primar3' 
actinomycosis  of  the  brain.  The  patient  was  26  years  of  age.  The 
intra  vitam  diagnosis  was  tumor  of  the  brain  ;  the  most  prominent  symp- 
toms were  severe  headache,  paral^'sis  of  left  abducens,  congestion  of 
optic  papilla,  and  momentary  unconsciousness.  The  swelling  in  the 
brain,  found  on  autopsy,  presented  the  characteristic  features  of  a  cysto- 
myxoma  in  the  third  ventricle ;  all  of  the  ventricles  were  found  consid- 
erably dilated.  The  swelling  contained  numerous  colonies  of  actinomyces 
in  all  possible  stages  of  development.  The  tendenc}-  to  suppuration  of 
the  tissues,  usually  found  in  all  cases  of  actinomycosis  in  man,  was 
entirely  absent  in  this  case.  This  case,  if  any,  appears  to  be  one  of 
cr^'ptogenetic  infection,  as  the  fungus  or  spores  must  have  entered 
somewhere  through  the  cutaneous  or  mucous  surface  without  producing 
the  disease  at  the  primary'  portio  invasionis^  and,  localizing  in  the  brain 
b}^  embolism,  resulted  in  primary  actinomycosis  in  this  organ. 

Keller  (Brit.  Med.  JouDial,  March  29,  1890)  reported,  this  year,  a 
case  of  metastatic  actinomycosis  of  the  brain  in  which  a  correct  diagnosis 
was  made  during  life.  The  patient  was  a  middle-aged  woman,  who 
suffered  from  pleurisy,  and  six  months  thereafter  abscess  developed  over 
the  cartilages  of  the  sixth  and  eleventh  ribs,  in  the  pus  of  which  actino- 
m^'ces  were  found.  Two  years  later  increasing  paresis  of  left  arm 
developed,  followed  b}'  convulsions,  confined  at  first  to  the  arm,  then 
becoming  general,  and  at  times  identical  with  cortical  epilepsy-.  Diag- 
nosis of  actinomycosis  affecting  the  motor  area  was  made  ;  operation  was 
suggested  and  declined.  The  paresis  extended  to  left  lower  extremity 
and  left  side  of  face  ;  later,  convulsions,  headache,  vomiting,  and  loss  of 
consciousness,  soon  deepening  into  coma.  Burger  then  obtained  consent 
to  operate.  The  patient  ■syas  moribund,  and  required  no  anaesthetic.  He 
exposed  the  right  ascending  parietal  convolution,  incised  the  dura  mater 


SiMPTO^MS    AND    DIAGNOSIS.  565 

and  the  discolored  brain-surface,  and  removed  2  ounces  of  thin,  greenish 
pus,  in  which  were  found  actinoin^ces  in  great  abundance.  When  the 
pus  was  evacuated,  she  recovered  from  the  deep  coma,  and,  while  still  on 
the  operating-table,  called  for  water.  On  the  following  day  consciousness 
returned,  and  on  the  eighth  the  facial  paralysis  disappeared.  In  two 
months  the  wound  had  healed  and  the  paralytic  lesions  improved,  but 
there  remained  some  paresis  of  left  arm,  with  contraction  of  the  fingers. 
In  less  than  one  year  there  was  a  recurrence  of  the  symptoms,  and  Burger 
re-opened  the  brain-abscess,  followed  by  the  escape  of  a  considerable 
quantitj'  of  pus.  No  material  improvement  followed,  and  the  patient 
died  a  few  days  thereafter. 

At  the  post-mortem,  the  middle  third  of  the  right  frontal  and 
parietal  convolutions  was  occupied  by  a  large  mass  of  newlj^-formed 
tissue,  protruding  over  the  surface  and  reaching  into  the  substance  of 
the  brain  for  one  inch.  Underneath  it,  deeply-  buried  in  the  white  sub- 
stance, an  unopened,  encapsulated  abscess,  the  size  of  a  nutmeg,  was 
discovered. 

SYMPTOMS   AND   DIAGNOSIS. 

Actinomycosis  is  an  inflammatory^  disease  that  clinically  is  noted 
for  its  chronicit}'.  The  specific  product,  composed  of  granulated  tissue, 
is  abundant,  and  the  swelling,  often  of  considerable  size,  resembles  more 
a  tumor  than  an  inflammatory  swelling.  The  extension  of  the  morbid 
process  takes  place  by  eflfusion  of  the  actinomyces  in  loco,  in  preference 
along  the  loose  connective-tissue  spaces,  each  fungus  constituting  a 
nucleus  for  a  nodule  of  granulation  tissue.  By  confluence  of  many  such 
nodules  the  inflammatory  swelling  often  attains  a  very  large  size,  and 
when  suppuration  occurs  in  the  interior  the  further  history  is  that  of 
chronic  abscess.  Regional  dissemination  of  the  infective  process  never 
takes  place  through  the  lymphatic  glands.  When  the  lymphatic  struc- 
tures become  implicated,  it  is  an  indication  that  secondary  infection  has 
taken  place.  In  exceptional  cases  the  disease  pursues  quite  a  rapid 
course,  and  may  then  be  mistaken  for  an  acute  phlegmonous  inflamma- 
tion, osteomyelitis,  or,  when  diffused  over  a  large  surface  of  the  bod^',  for 
syphilis.  A  good  illustration  of  the  former  class  is  furnished  by  the 
case  reported  by  Kapper.  A  soldier,  22  ^-ears  of  age,  became  suddenly 
ill  with  febrile  symptoms  and  a  rapidl^'-increasing  swelling  of  the  lower 
jaw.  An  early  incision  was  made  and  liberated  a  large  quantity  of  pus, 
which,  on  microscopical  examination,  was  found  to  contain  actinomyces. 
It  is  interesting  to  note  that  in  this  case  the  various  teeth  from  where 
the  infection  had  evidently  taken  place  contained  threads  of  leptothrix 
and  actinomyces. 

At  a  meeting  of  the  Berlin  Medical   Society,  about  two  years  ago. 


566  PRINCIPLES    OF    SURGERY. 

0,  Israel  gave  an  accurate  description  of  the  post-mortem  appearances 
of  a  case  of  diffuse  actinomycosis.  The  patient,  a  woman  44  years  of 
age,  had  been  treated  for  syphilis  in  one  of  the  surgical  clinics.  The 
heart  contained  a  number  of  minute  abscesses  containing  the  fungus  in 
large  numbers.  A  large  abscess  between  the  diaphragm,  stomach,  and 
spleen  contained  tliick  pus  of  a  greenish  color, — an  unusual  occurrence  in 
cases  of  actinomycosis, — but  no  actinomyces.  The  spleen  was  tlie  seat  of 
large  and  numerous  minute  abscesses,  and  the  liver  and  kidneys  also 
contained  small  abscesses,  and  in  all  of  them  actinomyces  were  found. 
Israel  claims  that  this  case  alfords  a  good  illustration  of  his  view  that 
the  actinomyces,  as  regards  its  effect  on  the  tissues,  occupies  a  position 
half-way  between  the  bacillus  of  tuberculosis,  which  produces  onl}' granu- 
lation tissue,  and  the  pus-microbes,  which  produce  pus.  It  was  im- 
possible in  this  case,  as  in  so  many  others  in  which  multiple  deposits 
have  been  found,  to  locate  with  accurac}'  the  primary  seat  of  infection. 
The  teeth  were  perfect  and  the  whole  digestive  tract  showed  no  evidence 
of  disease.  Metastasis  in  actinomycosis  takes  place  in  the  same  manner 
as  in  p3'8emia  and  malignant  tumors.  At  the  primary  seat  of  infection 
the  fungus  or  its  spores  gain  entrance  through  a  defective  vein-wall  into 
the  general  circulation,  and,  at  tlie  point  of  arrest  in  a  distant  capillar}- 
vessel,  establish  an  independent  centre  of  infection,  with  all  the  attri- 
butes of  tlie  primary  infection.  General  infection  is  of  rare  occurrence 
in  actinom3^cosis,  as  this  disease  is  noted  for  its  tendenc}'^  to  extend 
locally,  where  it  often  results  in  external  regional  dissemination  and 
destruction  of  tissue.  Actinomycosis  resembles,  in  its  clinical  behavior, 
very  closely  the  malignant  tumors,  in  that  it  will  invade  ever}^  tissue 
with  w^iich  it  comes  in  contact,  irrespective  of  its  anatomical  structure. 
Primary  localization  is  very  apt  to  occur  in  the  connective  tissue,  and  in 
preference  it  extends  along  this  structure;  but  periosteum, bone,  muscles, 
tendons,  cartilage, — in  fact,  all  of  the  tissues  of  the  bod}*, — succumb  to 
the  fungus  as  quickly  as  the}'  become  infected. 

In  actinomycosis  of  the  jaws  and  the  vertebra  we  often  find  exten- 
sive destruction  of  bone,  with  large  abscesses  communicating  with  the 
primary  lesion.  Before  suppuration  takes  place  the  actinomycotic  swell- 
ing is  quite  firm  on  pressure,  and,  if  the  disease  extend  rapidl}',  it  is 
surrounded  by  a  diffuse  oedema.  Pain  and  tenderness  are  usually  never 
severe,  and  often  almost  wanting.  Redness  appears  as  soon  as  the  in- 
fection has  extended  to  the  skin.  Suppuration  usually  develops  in  con- 
sequence of  direct  infection  with  pus-microbes  through  some  minute 
surface  defect  in  the  swelling.  As  soon  as  suppuration  sets  in,  the  swell- 
ing not  onl}'  increases  rapidly  in  size,  but  regional  diffusion  is  hastened 
by  the  breaking  down  of  the  granulation  tissue  that  before  held  the 


PROGNOSIS.  567 

fungi  fixed  in  their  respective  localities.  The  same  tendenc}'  to  migra- 
tion of  an  actinomycotic  abscess  is  observed  as  in  tubercular  abscess. 
The  characteristic  feature  of  actinomycotic  pus  is  the  presence  of  minute, 
macroscopical, yellowish  granules  ;  the  actinomyces,on  careful  inspection, 
can  almost  always  be  discovered.  If  these  granules  are  placed  under  the 
microscope  their  characteristic  structure  will  at  once  become  apparent. 

In  cases  of  actinomycosis  of  any  of  the  internal  organs,  attended  by 
suppuration  and  discharge  of  pus  through  some  one  of  the  outlets 
of  the  body,  the  diagnosis  will  usually  depend  almost  exclusively  upon 
the  detection  of  the  fungus  in  the  discharges.  Microscopical  examina- 
tion of  the  sputum  and  faecal  discharges,  in  cases  of  suspected  actinomy- 
cosis of  the  lungs  or  the  intestines,  is  the  onl}-  positive  means  of  making 
a  differential  diagnosis  between  these  affections  and  pulmonary  and  in- 
testinal tuberculosis.  Actinomycosis  of  the  skin,  mouth,  tongue,  and 
jaws  might  be  mistaken  for  sarcoma,  carcinoma,  tuberculosis,  and  sj-ph- 
ilis.  As,  with  the  exception  of  carcinoma,  all  of  these  affections  present 
under  the  microscope  a  histological  structure  that  it  would  be  often  dif- 
ficult to  identify  microscopically-,  tlie  differential  diagnosis  bj^  means  of 
the  microscope  must  rest  on  the  detection  of  the  raj'-fungus  imbedded  in 
the  granulation  tissue.  Sarcoma  does  not  suppurate  or  break  down  as 
early  as  the  actinomycotic  or  tubercular  swelling.  Carcinoma  primarily 
starts  in  the  epiblast  or  h3-poblast,  and,  even  during  the  earliest  period 
of  the  growth,  there  is  no  difficult}'  in  demonstrating  an  intimate  relation- 
ship between  the  skin  or  mucous  membrane  and  the  tumor  encroaching 
upon  the  mesoblast.  In  actinom^'cosis,  tissue  proliferation  takes  place 
around  each  fungus  in  the  mesoblast,  and  the  skin  or  mucous  membrane 
is  infected  and  destrov^ed  from  within  outward.  In  tuberculosis,  regional 
infection  almost  always  occurs  through  the  medium  of  the  lymphatic 
vessels  and  glands,  while  these  structures  are  seldom  or  never  invaded 
in  actinomycosis.  In  the  absence  of  microscopical  proof  of  the  nature 
of  the  lesion,  it  may  become  necessary  to  resort  to  a  therapeutic  test  in 
differentiating  between  syphilis  and  actinomycosis.  Large  doses  of  po- 
tassic  iodide,  administered  four  times  a  da}*,  will  have  a  decided  effect  in 
reducing  the  size  of  a  gumma  in  the  course  of  two  or  three  weeks,  while 
no  such  result  will  be  obtained  if  the  lesion  is  of  an  actinomycotic 
nature. 

PROGNOSIS. 

Actinomycosis  is  a  more  dangerous  affection  than  tuberculosis. 
While  a  spontaneous  cure  not  infrequently'  takes  place  in  the  latter,  we 
have  no  proof  that  actinomycosis  ever  terminates  in  such  a  satisfactory 
manner  without  the  surgeon's  aid.  Actinom3'cosis  of  the  internal  organs 
proves  fatal  almost  without  exception  on  account  of  the  inaccessibility 


568  PRINCIPLES   OF    SURGERY. 

of  the  disease  to  radical  surgical  treatment.  In  such  cases  numerous 
fistulous  openings  form,  discharging  profuse  quantities  of  pus,  and  the 
patient  dies  in  from  one  to  two  or  three  3'ears  from  exhaustion  or  am}'- 
loid  degeneration  of  the  internal  organs.  If  the  disease  is  located  in 
external  parts,  local  extension  often  takes  place  very  slowly  until  sup- 
puration sets  in,  when  the  actinomycotic  abscess  migrates  from  place  to 
place,  attacking  all  the  tissues  that  come  in  its  way,  and  life  is  finally 
destroyed  I)}'  pyaemia,  sepsis,  or  exhaustion.  The  prognosis  is  always 
favorable  when  the  disease  is  recognized  early,  and  when  it  is  located  in 
parts  accessible  to  a  radical  operation.  As  metastasis  is  of  rare  occur- 
rence in  actinom^'cosis,  complete  removal  of  the  primary  focus  is  followed 
by  a  permanent  cure. 

TREATMENT. 

General  treatment  in  actinoraj^cosis  is  of  no  avail,  and  all  local 
measures,  short  of  complete  removal  of  the  infected  tissues,  result  in 
more  harm  than  good,  as  the)''  often  give  rise  to  secondary  infection 
with  pus-microbes,  w^hich  alw^ays  aggravates  the  local  conditions  and 
hastens  a  fatal  termination.  In  cases  where  a  radical  operation  is  out 
of  question  on  account  of  the  extent  of  the  disease  or  the  importance 
of  organs  involved  in  the  process,  parenchymatous  injections  of  a  2-per- 
cent, solution  of  boric  acid,  a  1-to-lOOO  solution  of  corrosive  sublimate, 
or  a  l-to-1500  solution  of  nitrate  of  silver  might  be  tried  ;  but,  on  the 
■whole,  such  injections  have  little  influence  in  arresting  the  local  exten- 
sion of  the  disease.  The  surgical  treatment  of  actinomycosis,  before 
suppuration  has  occurred,  consists  in  the  excision  of  the  infected  tissues 
in  all  cases  where  such  a  procedure  is  practicable.  The  incision  should 
be  carried  some  distance,  at  least  I-  to  I  inch,  from  the  visible  granula- 
tions, with  a  view  of  removing  not  only  the  inflammator}-  tissue,  but  also 
the  minute  invisible  foci  in  its  immediate  vicinity.  If, after  the  excision, 
suspicious  tissue  is  found  in  the  wound,  this  should  be  removed  by  a 
careful  dissection  with  forceps,  knife,  and  scissoi-s,  or  destroyed  by  using 
the  actual  cautery.  Acids  and  other  chemical  caustics  should  not  be 
relied  upon  in  destro3-ingthe  infected  tissues.  An  actinomycotic  abscess 
should  be  treated  on  the  same  principles  as  a  tubercular  abscess.  The 
abscess-cavity  is  freely  exposed  by  lading  open  the  fistulous  openings, 
and  the  granulation  tissue  is  removed  with  a  sharp  spoon.  Undermined 
skin  is  cut  away  with  scissors.  If  the  disease  has  extended  to  bone,  this 
is  also  thoroughly  scraped,  and  it  is  a  good  plan,  after  the  cavity  has 
been  thoroughly  irrigated  and  dried,  to  cauterize  the  whole  surface  with 
the  actual  cautery.  Such  wounds  should  not  be  sutured,  but  packed  with 
iodoform  gauze  in  order  to  keep  the  infected  area  readily  accessible  to 
inspection,  so  as   to  enable  the  surgeon  at  each  dressing  to  recognize  a 


TREATMENT.  569 

local  recurrence.  Should  this  occur,  the  same  means  are  to  be  repeated 
in  eliminating  the  infected  tissues.  As  soon  as  the  wound  is  covered 
with  health}'  granulations  it  mu}-  be  closed  b}^  secondary  suturing,  or,  if 
this  cannot  be  done  on  account  of  too  great  loss  of  skin-tissue,  the  defect 
is  covered  with  large  skin-grafts  according  to  Thiersch's  method. 
Repeated  scraping  operations  will  often  succeed  in  finally  eradicating 
the  disease,  provided  the  infected  parts  are  accessible  to  vigorous 
curetting  and  the  application  of  the  actual  cautery. 


CHAPTER  XXIII. 

Anthrax. 

Synonyms:  Contagions  carbuncle  ;  cliarl)on  ;  Milzbrand  ;  malignant 
pustule;  wool-sorters' disease.  The  ni3cology  of  anthrax  is  better  under- 
stood than  that  of  an}  other  niicrobic  disease.  The  bacillus  of  anthrax 
is  the  largest  of  the  known  pathogenic  microbes,  and  ever  since  it  was 
discovered  it  has  been  a  favorite  subject  of  investigation  in  every  labora- 
tory and  by  every  bacteriologist. 

HISTORY. 

As  a  disease  among  animals,  anthrax  has  been  known  since  the 
earliest  records  of  historv.  The  contagiousness  of  this  disease  has  been 
recognized  since  the  beginning  of  the  eighteenth  centur}'.  During  the 
first  part  of  the  present  century  it  was  described  as  a  blood  disease. 
Heusinger.  in  his  classical  work,  "  Die  Milzbrand  Krankheiten  der  Thiere 
nnd  des  Menschen  "  (Erlangen,  1850),  declared  anthrax  to  be  a  malarial 
neurosis.  In  the  year  1855  Pollender  published  his  discoveries,  which 
inaugurated  a  new  era  in  the  study  of  anthrax.  As  early  as  1849  he 
discovered,  in  the  blood  of  cattle  suffering  from  anthrax,  a  mass  of  innu- 
merable, fine,  rod-like  bodies,  which  appeared  to  be  of  a  vegetable  nature 
and  resembled  vibriones.  Branell  found  the  same  rods  in  the  blood  of 
men,  horses,  and  sheep  which  had  died  of  anthrax.  He  also  detected 
the  same  bodies  during  life  in  the  blood  of  the  diseased  animals.  Dela- 
fond  regarded  this  parasite  as  a  variet}'  of  leptothrix.  In  1863  appeared 
the  work  of  Davaine,  wherein  he  pronounced  these  rods  to  be  bacteria, 
.and  later  he  called  them  bacteridia.  He  believed  them  to  be  the  essential 
cause  of  anthrax,  as  the  disease  could  not  be  found  in  blood  that  did  not 
contain  them.  Through  the  labors  of  Pasteur,  Koch,  Nsegeli,  Bollinger, 
and  others,  the  bacterium  found  so  constantly  in  the  blood  and  tissues 
of  anthracic  animals  finally  found  a  permanent  place  as  the  bacillus 
anthracis  among  the  schizomA'cetes. 

The  first  reliable  and  positive  accounts  of  the  disease  in  man  we  owe 
to  Fournier,  Montfils,  Thomassin,  and  Chabert,  who  published  their  de- 
scription of  the  disease  between  the  j-ears  1769  and  1780.  Fournier  first 
distinguished  the  spontaneous  and  the  communicated  carbuncle  of  man. 
The  primary  existence  of  anthrax  in  man  was  asserted  by  Bayle  in  1800 
and  bv  Bsivy  la  Chevrie  in  1807. 

(571) 


672 


I'lUNCIFLES    OF    SURGERY. 


DESCRIPTION    OF    THE    BACILLUS   OF    ANTHRAX. 

Non-motile  rods,  5  to  10  micro-millimetres  long  and  1  to  1.25  micro- 
millimetres  broad,  and  threads  made  up  of  rods  and  cocci. 

The  rods,  as  a  rule,  are  straight ;  only  when  they  grow  to  a  con- 
siderable length  and  meet  with  resistance  they  become  slightly  curved. 
The  rods  and  threads  are  round,  and,  with  their  threads  truncated  at 
right  angles,  appear  as  though  they  had  been  cut  otf  obliquely.  The 
interior,  as  long  as  lission  does  not  proceed,  is  perfectly  homogeneous, 
and  absorlts  aniline  dyes  very  readily  and  uniformly.  The  development 
of  spores  in  long,  undivided  threads,  as  we  find  them  in  fluid  culture 
media,  takes  place  at  regular  intervals,  where  we  find  them  as  bright,  oval 
spots  that  become  more  and  more  apparent,  marking  tlie  direction  of  the 
rods.     Upon  solid  culture  media  the  development  of  spores  is  preceded 


<^ 


0     6bi>    «» 


Fig.  102.— Anthrax  Bacilli.    Spoke  Formation  anb  Spore  Germination. 

(Koch.) 

a.  From  the  spleen  of  a  mouse  after  twenty-four  hours'  cultivation  in  aijuenus  humor.  Spores 
arranged  in  rods  like  a  string  of  pearls.  X650.  B.  Germination  of  spores.  X^50.  C.  The  same 
greatly  magnified.    X  ItioU. 


by  transverse  segmentation  of  the  rods.  The  cell-membrane  of  each 
section  finally  becomes  the  membrane  of  the  spore,  each  pole  of  the 
spore  presenting  a  small  mass  of  protoplasm  that  can  be  stained. 

(a)  Staining. — Cover-glass  preparations  of  fluid  specimens  can  be 
stained  with  a  waterj'  solution  of  any  of  the  aniline  dyes.  They  can  be 
rapidl}-  stained  with  a  drop  of  fuchsin  or  gentian-violet,  but  more  satis- 
factorily' b}'  floating  tlie  cover-glass  for  twent3'-four  hours.  The  prepara- 
tions are  dried  and  mounted  in  Canada  balsam.  The  spores  are  not 
stained  by  the  ordinary  methods.  Tissue-sections  containing  bacilli  are 
best  stained  b}-  Gram's  method,  and  after-stained  with  eosin  or  picro- 
carminate  of  ammonium.  By  double  staining  the  rods  are  seen  to 
consist  of  a  hy.iline  sheath  with  protoplasmic  contents. 

(b'i  Cultivation. — The  bacillus  of  anthrax  grows  luxuriantly  in  dif- 


ANTHRAX    BACILLI    IN    THE    LIVING    BODY    AND    THE    SOIL.       ,'u'S 


forent  fluid  and  solid  nutrient  medio.  Bouillon  and  aqueous  humor  of 
the  eye  furnish  an  excellent  soil,  but  for  inoculation  purposes  the  cultures 
are  now  generallj^  grown  upon  solid  nutrient  media. 

Gelatin. — If  a  nutrient  medium  containing  from  5  to  8  per  cent,  of 
gelatin  is  inoculated,  a  whitish  line  develops  in  the  track  of  the  needle- 
puncture,  and  from  it  fine  filaments  spread  out  on  the  sides. 

In  a  more  solid  nutrient  gelatin  the  growth  appears  only  as  a  thick, 
white  thread.    The  culture  liquelies  the  gelatin, and 
the  growth  subsides  as  a  white,  flocculent  mass. 

Plate  Cultures. — Cultures  upon  a  sloping  sur- 
face of  solid  nutrient  agar-agar  or  gelatin  form  a 
viscous,  snow-white  plaque. 

"Without  access  of  air  the  culture  does  not 
grow,  the  bacilli  being  aerobic. 

Potato. — Inoculation  of  sterilized  potato  yields 
a  very  characteristic  growth.  The  deep  chamber 
containing  the  potato  is  placed  in  the  incubator, 
and  in  about  thirty-six  or  forty-eight  hours  a 
creamy,  very  faintly  yellowish  layer  forms  over  the 
inoculated  surface,  with,  usuallv,  a  pecxiliar  trans- 
lucent edge.  On  removing  the  cover  of  the  damp 
chamber,  a  strong,  penetrating  odor  of  sour  milk  is 
emitted. 

MULTIPLICATION    OF    ANTHRAX   BACILLI    IN    THE 
LIVING    BODY    AND     THE   SOIL. 

In    the    body    of    living    animals    the    bacilli 

multipl}'  exclusively  b}'  segmentation,  and  never 

produce  spores.    Spores  are  produced  only  in  dead 

nutrient  media,  and  under  certain  conditions  only,     PERATUREa6°Toi8°c.). 
'  •'  '      Four  Days  Old.  Natu- 

among  which  a  proper  temiierature  is  the  most  im-     ^^^  f^A^^"        ,     > 
portant   factor.      The    limits  of   the   temperature 

vary  between  12  to  18°  C.  and  43°  C. ;  at  a  temperature  of  less  than 
12°  C.  growth  of  the  rods  and  spore  production  no  longer  take  i)lace. 
Pasteur's  assertion  that  bacilli  and  spores  in  the  cadavers  of  bui-ied 
animals  are  active  Avhen  l)rought  to  the  surface  by  earth-worms  is  im- 
probable. The  disease,  according  to  Koch,  is  spread  among  animals 
by  germinating  spores  which  attach  themselves  to  plants  and  grass  in 
swamps  and  along  river-banks,  and  which,  when  taken  in  with  the  food, 
become  the  cause  of  intestinal  anthrax. 

Schrakamp  and  Friedrich  are  of  the  opinion  that  bacilli  can 
multiply  in    the    superficial    layer   of    the    soil,   while    Kitt   maintains 


Fig.  loa.— Stab  Cul- 
ture OF  Anthrax 
Bacilli  in  Gelatin, 
Grown   at  Room-Tem- 


574 


PRTNCIPLKS   OF    SURGERY. 


lli.'it   fructitication  of   the   l):iciUi    takes  place  in   tlio   manure    deposited 
in  pastures. 

INOCULATION    EXPERIMENTS. 

In  order  to  cause  death  of  animals  b^  inoculation  with  the  bacillus 
of  anthrax,  a  pure  culture  or  anthracic  blood  must  be  injected  into  the 
subcutaneous  tissue  or  into  the  circulation,  or  the  virus  may  be  trans- 
mitted by  inhalation  or  b}-  feeding.  Goats,  hedgehogs,  mice,  sparrows, 
cows,  horses,  guinea-pigs,  and  sheep  can  l)e  readily  infected.  Rats 
are  less  susceptible.  Pigs,  dogs,  cats,  white  rats,  and  Algerian 
sheep  are  immune.  Frogs  and  fish  have  been  rendered  susceptible  to 
anthracic  infection  by  raising  the  temperature  of  the  water  in  which  they 


,^-,/?=»;)))  fr^''~ 


Pf^M  ^  ^ 


'S-.    B 


Fig.  104.— Anthrax  Colony  upon  Gelatin.    x80.     (Fluegge.) 

A,  after  tnenty-four  hours  :  B,  after  forty-eight  hours. 

lived.  Koch  produced  the  disease  artificially  in  rabl^its  and  mice  by 
injecting  a  drop  of  anthracic  blood,  with  the  result  of  producing  death 
usually  within  twenty-four  hours.  After  death  sections  taken  from 
dirterent  organs,  stained  in  methyl-violet  with  carbonate  of  potash,  were 
examined  under  the  microscope,  and  the  Ijacillus  was  found  in  great 
uliundance  in  all  of  them.  When  magnified  fifty  diameters  such  prepara- 
tions present,  at  the  first  glance,  an  appearance  as  if  a  blue  coloring 
material  had  been  injected  into  the  vessels.  Each  intestinal  villus  is 
permeated  by  an  exceedingly  delicate  blue  net-work;  in  the  mucous 
membrane  of  the  stomach  all  the  capillaries  surrounding  the  gastric 
glands  are  stained  blue ;  in  the  ciliary  processes  each  projection  is 
injected,  and  a   spiral   vessel  stained   of  a  dark-blue  color  leads   from 


INOCULATION    EXPERIMENTS. 


O  ir> 


thence  to  the  iris  and  breaks  np  into  a  fine,  blue  net-work,  with  loops 
directed  toward  the  edge  of  the  iris.  The  liver  and  lungs  and  the 
glandular  structures,  such  as  the  pancreas  and  salivary  glands,  are  com- 
pletelj'  permeated  by  the  same  blue,  vascular  net-work.  Indeed,  there  is 
no  organ  which  is  not  more  or  less  injected  with  the  blue  mass.  It  is, 
however,  ver}'  striking  that  this  injection  is  only  present  in  the  capillar}' 
vessels.  All  the  larger  vessels,  even  the  arteries  and  veins  of  an  intes- 
tinal villus,  are  either  not  at  all  stained  or  have  but  a  light-blue  streak  in 
their  interior,  and  that  only  here  and  there.  When  magnified  250  times 
one  can  see  that  the  blue  capillary  net-work  is  composed  of  numerous 
delicate  rods,  and  when  a  power  of  700  diameters  is  used  it  is  found  that 


K[^  1 


Fig.  105.— Intestinal  Villus  of  Anthracic  Rabbit.    The  Bacilli  in  Capillary 
Vessels  Alone  Stained.    x250.    (Koch.)* 

the  apparent  injection  is  nothing  more  or  less  than  the  bacillus  anthracis, 
stained  dark-blue,  and  present  in  incredible  numbers  in  the  whole 
capillary  system. 

In  the  other  vessels,  especially  in  the  larger  ones,  often  only  a  single 
li:icillus  may  be  met  with  at  long  intervals,  or  they  ma}'  be  quite  absent. 

The  distribution  of  the  bacillus  in  the  capillaries  is  not,  however, 
iiuite  uniform.  There  are  fewer  in  the  brain,  in  the  skin,  in  the  capil- 
laries of  the  muscle,  and  in  the  tongue  than  elsewhere  ;  on  the  other 
hand,  in  the  liver,  lungs,  kidney's,  spleen,  intestines,  and  stomach  the}' 
are  always  present  in  enormous  numbers.     In  the  capillaries  themselves 


»  Copied  from  "  Traumatic  Infective  Diseases,"  by   permission  of  the  New  Sydenham 
Society,  London. 


576  rKix^'iPLEs  OF  si'HfjEin*. 

tlie  bacilli  accumulate  in  largest  numbers  at  the  i)oint  most  distant  from 
the  nearest  afferent  artery  and  the  efferent  vein, — that  is,  at  points  where 
the  blood-current  is  sloM'est.  Where  the  bacilli  are  present  in  greatest 
abundance  it  not  unfrequently  happens  that  the  capillaries  become 
torn,  and  blood  with  the  contained  bacilli  is  extra vasated.  This  occurs 
most  frequently  iu  the  glomeruli.  Man}*  of  these  burst,  and  the  bacilli 
pass  into  the  uriniferous  tubules.  In  mice  the  spleen  is  more  especially 
the  seat  of  the  bacilli ;  then  come  the  lungs,  and,  last  of  all,  the  kidneys. 
Frisch  inoculated  tiie  cornea  in  animals  and  produced  a  keratitis,  caused 
by  the  bacilli,  which  multiplied  with  great  rapidit}^,  local  dissemination 
taking  place  through  the  corneal  spaces. 

INFECTION    IN   MAN. 

An  intact  skin  furnishes  ample  protection  against  infection  with 
bacilli  or  spores,  but  the  slightest  abrasion  ma}-  become  the  necessary 
infection-atrium  for  either  method  of  infection.  Infection  ma}'  occur 
through  a  health}'  mucous  membrane,  either  with  bacilli  or  spores.  As 
the  anthrax  bacillus  is  a  non-motile  parasite,  penetration  of  the  epithelial 
lining  can  onl}^  occur  b}'  local  growth  of  the  bacillus.  Spores  are  such 
minute  structures  that  they  can  reach  the  circulation  through  a  healthy 
mucous  membrane  in  the  same  manner  and  b}'  means  of  the  same 
agencies  as  we  have  found  necessary  for  the  transportation  of  other 
minute  foreign  parasites  from  a  mucous  surface  into  the  circulation.  In 
man  infection  frequently  takes  place  through  a  small  wound  or  abrasion 
in  persons  handling  the  infected  products  of  anthracic  animals,  such  as 
wool,  hair,  and  hides.  In  other  instances,  insects,  such  as  mosquitoes 
and  flies,  that  have  fed  on  the  blood  of  living  anthracic  animals  or  the 
dead  tissues  of  animals  that  died  of  the  disease,  may  become  disease 
carriers.  The  sting  of  such  an  infected  insect  may  communicate  the 
disease  with  the  same  degree  of  certainty  as  an  intentional  inoculation 
with  a  drop  of  anthracic  blood  or  a  minute  quantity  of  a  pure  culture. 

INTENSIFICATION    OF   VIRUS. 

While  it  is  known  that  some  chemical  substances  exert  an  attenuating 
influence  on  the  virulence  of  the  anthrax  bacillus,  it  has  also  been  found 
that  an  attenuated  virus  will  again  become  more  virulent  by  adding 
certain  substances.  It  must,  therefore,  be  taken  for  granted  that  the 
chemical  composition  in  which  the  bacillus  is  suspended  influences,  in  one 
wa}'^  or  the  other,  its  virulence.  It  has  been  found,  for  instance,  that  tlie 
addition  of  a  minute  quantit}'  of  lactic  acid  to  a  fluid  containing  the 
bacillus  in  an  attenuated  form  greatl}'  intensifies  its  virulence  within  a 
very  short  time.     Thus,  Arloing,  Cornevin,  and  Thomas  found  that  the 


ATTENUATION    OF   VIRUS    AND    PROPHYLACTIC    INOCULATIONS.       577 

pathogenic  power  of  a  fluid  containing  these  bacilli,  to  which  ^Jg  part 
of  lactic  acid  had  been  added,  and  the  mixture  allowed  to  stand  for 
twenty -four  hours,  was  increased  twofold;  if,  then,  a  little  w-ater,  con- 
taining a  very  easily  fermentescible  sugar,  is  added  to  the  mixture,  and 
another  twenty-four  hours  allowed  to  elapse,  the  virulence  nttains  its 
maximum,  and  frogs  inoculated  with  this  virus  die  in  from  twelve  to 
fifteen  hours;  whereas,  when  inoculated  with  ordinary  virus,  the^'  live 
from  fort}^  to  fift}'  hours.  Kitt  has  repeated  and  confirmed  these  experi- 
ments. 

ATTENUATION  OF  VIRUS  AND  PROPHYLACTIC  INOCULATIONS. 
^y  cultivating  the  bacillus  of  anthrax  in  neutralized  bouillon  at 
42°  to  43°  C.  (107.6°  to  109.4°  F.),  for  about  twenty  days,  the  infecting 
power  is  weakened,  and  animals  inoculated  with  it  are  protected  against 
the  disease.  A  still  greater  degree  of  immunity  is  obtained  by  inoculat- 
ing a  second  time  with  material  that  has  been  less  weakened.  Animals 
thus  treated  are  then  protected  against  the  most  virulent  form  of  anthrax, 
but  only  for  a  time.  A  temperature  of  55°  C.  (131°  F.),  or  treatment 
with  1-  to  5-per-cent.  solution  of  carbolic  acid,  deprives  the  bacilli  of 
their  virulence.  The  virulence  of  the  bacillus  is  also  altered  by  passing- 
it  through  different  species  of  animals.  Woolbridge  secured  immunity 
against  anthrax  in  animals  by  cultivating  the  bacillus  in  an  alkaline 
solution  at  a  temperature  of  37°  C.  (98.6°  F.)  for  two  days.  At  this 
time  the  fluid  was  filtered,  and  a  small  quantity  of  the  filtrate  injected 
into  the  subcutaneous  tissue  of  rabbits  ;  these  rabbits  remained  well,  and 
subsequently  resisted  injection  of  most  virulent  anthracic  blood. 

Hankin,  under  the  guidance  of  Koch,  at  the  Hygienic  Institute  of 
Berlin,  isolated  an  albuminose  from  anthrax  cultures,  which,  when  in- 
jected into  rabbits  and  mice  in  small  quantities,  rendered  these  animals 
immune  against  the  most  virulent  cultures.  The  albuminose  was  pre- 
pared from  the  cultures  by  precipitation  with  absolute  alcohol ;  the 
precipitate  was  well  washed  in  this  liquid  to  free  it  from  ptomaines, — 
since  it  is  known  that  all  such  substances  are  soluble  in  alcohol.  After 
the  addition  of  alcohol  it  w^as  filtered  off  and  dried,  then  re-dissolved, 
and  filtered  through  Chamberland's  filter.  Four  rabbits  were  inoculated 
with  virulent  anthrax  spores,  and  3  of  them  received  an  injection  of 
albuminose  into  the  ear-vein  at  the  same  time;  the  latter  recovered,  wdiile 
the  remaining  animal  not  thus  protected  died,  in  about  fort3^-eight  hours, 
of  anthrax.  In  another  experiment,  10  mice  were  each  injected  with  the 
millionth  part  of  their  bod3'-w^eight  of  anthrax  albuminose  and  with 
active  vaccine  at  the  same  time.  Of  these  3  died  after  108  to  116  hours  ; 
the  others  recovered.     Three  others  had  only  the  two-millionth  part  of 


578  PRINCIPLES    OF    SURGERY. 

their  bod \' -weight  of  anthrax  albiiminose  and  active  culture.  Two  of 
them  survived.  Four  control  mice  were  inocuhited,  and  all  died 
of  anthrax.  He  has  come  to  the  conclusion  that  wlien  a  large  dose  of 
albuminose  is  injected  into  an  animal  the  entrance  of  anthrax  bacilli 
into  tlie  system  is  aided,  and  when  a  small  dose  is  administered  imnui- 
nitj'  is  acquired  against  its  poisonous  properties,  protecting  the  animal 
against  subsequent  inoculations  with  active  cultures.  Prophylactic 
inoculations  of  sheep  with  mitigated  virus  is  carried  on  upon  an  exten- 
sive scale  in  France  by  Pasteur  and  his  pupils,  and  recent  statistics 
bearing  upon  their  value  in  protecting  the  animals  against  anthrax  have 
shown  them  effective  in  preventing  the  spread  of  the  disease  in  infected 
districts. 

CLINICAL   VARIETIES    OF    ANTHRAX, 

PriuKuy  bronchial  and  pulmonar}'  anthrax,  caused  b}- the  inhalation 
of  dust  containing  bacilli  or  spores,  and  primary  anthrax  of  the  intes- 
tines, caused  by  eating  anthracic  meat  or  by  drinking  water  infected 
with  spores,  are  diseases  that  are  occasionally^  met  with  in  man ;  but,  as 
these  affections  belong  to  the  physician  and  not  to  the  surgeon,  the 
student  should  consult  any  of  the  modern  text-books  on  the  practice  of 
medicine  to  become  familiar  with  their  sj^mptomatology. 

Buchner  has  studied  experimentall3^  the  entrance  of  the  anthrax 
bacillus  through  the  intact  mucous  membrane  of  the  bronchial  tubes. 
The  bacillus  and  spores  were  administered  by  inhalations,  in  the  shape 
of  dry  powder,  and  suspended  in  steam.  On  examining  the  bronchial 
mucous  membrane  at  different  stages  under  the  microscope,  it  was  seen 
that  the  spoi'es  were  transformed  in  a  very  short  time  into  bacilli,  and 
that  the  latter,  by  their  growth,  pushed  themselves  between  the  cells  and 
into  the  capillary  vessels.  It  was  observed  that  the  greater  the  pulmo- 
nary irritation,  the  more  the  passage  of  the  microbes  was  retarded.  The 
entrance  of  the  bacilli  from  the  surface  of  the  mucous  membrane  into 
the  capillary  vessels  was  seen  to  depend  on  an  active  process. 

Secondary  anthracic  bronchitis,  pneumonia,  and  enteritis  are  met 
with  in  almost  all  cases  of  localized  anthrax  followed  by  secondary 
general  infection.  Primary  intestinal  anthrax  in  man  was  studied  by 
Wahl,  Recklinghausen,  Buhl,  Wagner,  Bollinger,  Leube,  and  Frankel, 
and  all  of  these  authors  succeeded  in  demonstrating  the  presence  of  the 
essential  microbic  cause  in  the  inflamed  mucous  membrane.  When  the 
microbe  enters  the  body  through  the  mucous  membrane  of  the  gastro- 
intestinal canal  with  the  food  or  drink,  it  gives  rise  to  a  primar}' anthrax 
of  the  intestinal  canal,  that  again  may  become  general  by  metastatic  dis- 
semination through  the  systemic  circulalioii.  Localization  upon  the 
mucous  surface  first  takes  place   upon  the  most  prominent  part  of  the 


CLINICAL    VARIETIES   OF    ANTHRAX.  579 

valvulse  conniventes  on  the  mesenteric  side  of  the  bowel,  and  from  here 
the  infection  spreads  over  the  entire  siirfnce.  Vierhoft'  lias  collected  41 
cases  of  anthrax  intestinalis,  the  total  number  found  rei)orted  up  to  1885. 
The  author  himself  observed  2  cases  of  secondary  intestinal  anthrax  in 
the  hospital  at  Riga.  Cases  of  secondarj'  intestinal  anthrax — that  is. 
localization  of  the  bacillus  of  anthrax  in  the  mucous  membrane  of  the 
intestinal  canal  after  external  infection — were  known  to  the  older  authors 
while  observations  of  primarj'  localization  in  the  digestive  tract  date 
onl^-  from  the  middle  of  the  last  century.  As  soon  as  general  infection 
has  taken  place,  the  diffusion  throughout  the  capillary  system  is  the 
same  as  has  been  described  under  the  head  of  Inoculation  Experiments. 
The  forms  of  anthrax  that  concern  the  surgeon  most  are  those  whicli 
result  from  infection  of  the  external  surface  by  the  introduction  of  the 
bacilli  or  spores  through  a  small  wound,  abrasion,  or  the  stins:  of  an 
infected  insect.  The  favorite  location  for  the  development  and  growth 
of  the  anthrax  bacillus  in  man  and  beast  is  in  the  connective  tissue;  it 
is,  therefore,  immaterial  in  what  manner  the  microbe  reaches  this  tissue, 
as  localization  here  marks  the  beginning  of  the  disease.  The  clinical 
forms  vary  according  to  the  location  of  the  disease,  its  extent,  and  the 
intensit}'  of  the  infection.  Most  all  authors  follow  Bollinger's  classifica- 
tion, according  to  which  all  cases  are  brought  under  one  of  the  follow- 
ing varieties  :  1.  Anthrax  acutissimus,  or  apoplectiformis.  2.  Aciitis. 
3.  Subacutis. 

The  primary  location  of  the  disease  is  in  accordance  with  the  manner 
in  which  infection  has  taken  place.  W.  Koch  states  that  in  animals  and 
man  the  bacillus  can  enter  the  organism  through  one  of  the  following 
routes  :  (a)  through  the  skin  ;  (6)  gastro-intestinal  canal  ;  (c)  respirator^' 
passages. 

Anthrax  of  the  Externa!  Surface.— Infection  of  the  sub-epidermal 
connective  tissue  can  onl^'  occur  through  a  defect  in  the  epidermis  ; 
hence,  ever}-  anthrax  of  the  external  surftice  corresponds  in  its  location 
with  an  infection-atrium,  through  which  the  essential  microbic  cause 
has  entered  the  connective  tissue.  The  bacillus  of  nnthrax,  when  brought 
in  contact  with  living  tissue  susceptible  to  its  pathogenic  action,  causes 
an  acute  inflammation  characterized  by  grave  alterations  of  the  capillary 
wall  and  rapid  exudation.  The  microbe  first  multiplies  at  the  primary 
point  of  invasion,  and,  if  it  does  not  meet  with  suthcient  tissue  resist- 
ance, it  enters  the  blood-vessels  and  causes  general  infection,  whicli  always 
proves  fatal.  Infection  occurs  most  frequently  in  exposed  parts  of  the 
bod}';  thus,  of  63  cases  of  anthrax  in  man,  collected  b}'  Slessarewskji, 
the  disease  showed  itself  6  times  on  the  face,  21  times  on  the  neck,  and 
36  times  in  other  places.     Trousseau  relates  that  in  Paris  20  persons 


580  PRINCIPLES   OF    SURGERY. 

were  attacked  with  anthrax  in  ten  years,  and  in  all  of  them  the  source 
of  infection  could  be  traced  to  horse-hair  imported  from  South  America. 
The  pathologico-anatomical  conditions  var^^  according  to  the  primarj' 
seat  of  invasion,  the  structure  of  the  organ,  and  seat  of  the  disease. 
The  first  tissue  changes  are  observed  at  the  point  of  inoculation.  From 
a  prognostic  and  pathological  point  of  view,  external  anthrax  can  be 
divided  into  two  distinct  varieties  :  1.  Anthrax  pustule.  2.  Anthrax 
cedema. 

1.  Anthrax  Pustule. — This  is  the  so-called  malignant  pustule.  It  is 
usually  met  with  iu  parts  not  covered  b3'  clothing,  as  the  fingers,  hands, 
and  face.  This  form  of  the  disease  is  determined  b}^  the  anatomical 
structure  of  the  part  affected,  which  must  be  dense  and  vascular.  The 
pustule  begins  as  a  small,  red  point  that  resembles  the  ])ite  of  a  flea,  in 
the  middle  of  which  a  small  vesicle  appears,  which,  at  first,  contains  a 
transparent  serum,  and,  later,  becomes  sanguineous.  The  patient  com- 
plains of  an  itching,  burning  sensation.  The  skin  around  the  centre  of 
the  pustule  is  at  first  slightly  raised  by  the  inflammatory  infiltration 
underneath  it.  Within  twenty-four  or  forty-eight  hours  the  size  of  the 
infiltrated  area  is  as  large  as  a  nickel,  and  the  inflamed  part  presents  all 
the  evidences  of  a  very  acute  circumscribed  inflammation.  The  swelling 
is  now  painful,  tender  on  pressure,  and  exceedingly  firm  to  the  touch. 
The  centre,  previously  occupied  by  a  vesicle,  is  of  a  brownish-red  or 
blackish-gray  color,  and  presents  indications  of  approaching  gangrene. 
The  epidermis  exfoliates,  exposing  a  neci'osed  area  the  size  of  a  pea  to 
a  silver  half-dollar.  The  dead  tissue  remains  firmlj'  connected  with  the 
surrounding  indurated  parts,  until  it  becomes  gradually  detached  in  the 
course  of  the  suppurative  inflammation,  which  ensues  sooner  or  later. 
After  separation  of  the  slough,  spontaneous  healing  ma}'  take  place, 
alwaj'S  leaving  a  depressed  scar.  In  this  form  of  anthrax  general  infec- 
tion seldom  occurs,  as  the  infection  remains  local,  the  early  and  abun- 
dant inflammatory  exudation  forming  an  impermeable  wall  around  the 
infected  zone,  beyond  which  the  bacilli  cannot  escape.  General  infection, 
however,  in  such  cases  occasionally  takes  place  where  a  vein  becomes 
implicated  in  the  process,  and  general  infection  is  not  prevented  by  the 
formation  of  a  plastic  thrombus  on  the  proximal  side  of  the  intra-venous 
culture.  The  acuteness  of  the  inflammation,  and  probably,  also,  the 
direct  necrotic  eff'ect  of  the  ptomaines  of  the  bacilli,  invariabl}'  result  in 
necrosis  of  the  central  portion  of  the  pustule,  which  is  the  most 
characteristic  pathological  and  clinical  feature  of  this  form  of  anthrax. 

2.  Anthrax  (Edema. — This  form  of  anthrax  follows  infection,  if  the 
tissues  around  the  infection-atrium  are  freely  supplied  with  loose  con- 
nective tissue  and  the  blood-supply  to  the  part  is  scanty, — conditions 


PATHOLOGY    AND    MORBID    ANATOMY.  581 

which  are  present  about  the  eyelids,  neck,  and  forearm.  Anthrax  in 
these  localities  appears  as  a  flat  infiltration  without  well-defined  borders, 
and  with  little  or  no  discoloration  of  the  skin.  From  the  infiltrated 
tissues  a  rapidly-spreading  oedema  extends  in  all  directions.  This  form 
of  anthrax  is  attended  by  greater  danger  of  general  infection  than  an- 
thrax pustule,  as  the  bacilli  are  less  effectually  walled  in  b}'  the  inflam- 
matory product.  Vesication,  exfoliation  of  cuticle,  and  gangrene  may 
also  take  place,  and  in  milder  cases  a  spontaneous  cure  is  possible.  As 
long  as  the  infection  remains  local  general  symptoms  are  absent,  but  as 
soon  as  general  infection  has  occurred  the  sjanptoms  point  to  progressive 
septicaemia. 

PATHOLOGY    AND    MORBID    ANATOMY. 

If  the  tissues  of  a  primary  anthrax  of  the  external  surface  are 
examined  under  the  microscope,  all  the  appearances  of  an  acute  non- 
suppurative inflammation  are  shown.  The  specific  effect  of  the  bacillus 
on  the  tissues  results  in  serious  alteration  of  the  capillary  vessels,  which 
gives  rise  to  an  abundant  inflammatory  exudation.  In  malignant  pus- 
tule, or  anthrax  pustule,  the  para-vascular  and  connective-tissue  spaces 
become  completely  blocked  with  leucocytes  in  a  remarkably  short  time, 
and  necrosis  of  the  central  portion  of  the  inflammatory  product  is  a 
constant  residt  of  the  acute  ischa;mia  and  the  speedy  coagulation  necrosis 
thus  produced.  Anthracic  inflammation  never  terminates  in  suppura- 
tion unless  secondary  infection  with  pus-microbes  takes  place.  The  local 
oedema  in  the  oedematous  variety,  at  the  point  of  infection,  is  caused  by 
vascular  disturbances  due  to  the  presence  of  the  bacilli  witliin  the  blood- 
vessels and  the  interstitial  inflammatory  exudation  caused  bj'  their  pres- 
ence. In  fatal  cases  the  necrops}'  reveals  the  same  changes  in  different 
organs  as  Koch  has  described  in  his  experiments  on  rabbits.  The  capil- 
lary vessels  in  every  part  of  the  body  will  be  found  completely  or  par- 
tially blocked  with  bacilli,  but  the  number  of  microbes  is  always  greatest 
in  the  most  vascular  organs,  as  the  spleen,  liver,  and  kidneys. 

Tlie  bacilli,  as  in  mice-septiccemia,  will  be  found  in  the  capillary  ves- 
sels arranged  in  the  direction  of  the  blood-current,  and  most  numerous 
where  the  flow  of  blood  is  most  impeded,  as  at  points  of  intersection. 
General  infection  always  takes  place  through  blood-vessels.  The  inter- 
nal organs  are  found  enlarged  and  exceedingly  vascular  from  engorge- 
ment caused  by  the  capillar}'  obstruction.  Minute  extravasations  are 
found  in  different  organs  where  the  bacilli  are  most  numerous,  resulting 
in  complete  destruction  of  the  capillary  wall  and  rhexis.  The  secondary 
intestinal  affection  most  frequently  assumes  the  form  of  inflammatory 
hsemorrhagic  infiltration,  more  seldom  that  of  haemorrhagic  catarrh; 
ulcerations  the  size  of  a  split  pea  to  2  inches  in  diameter  are  frequently 


582 


FKINCIPLES   OF    SURGERY. 


present,  the  remaining  portion  of  the  mucous  membrane  showing  well- 
marked  evidences  of  acute  inflammation,  great  vascularity,  and  infiltra- 
tion. Mesenteric  glands  are  swollen  and  contain  numerous  bacilli.  The 
bronchial  and  intestinal  mucous  membranes  show  all  the  appearances  of 
recent  inflammatory  changes,  great  vascularity,  slight  thickening,  and 
here  and  there  minute  extravasations.  In  some  cases  the  meninges  of 
the  brain  show  well-marked  lesions  that  account  for  the  cerebral  symptoms 
during  life.     Pathologists  have  often  failed  in  locating  the  immediate 


mlmmi 

P  pil  1^9, m^i  m 

I  \v>  f»Mi  iri^  vMBji'  ^^^^ 


Fig.  106.— Anthrax.    Section  from  Liver,    x  700.    {Fluegge.) 

cause  of  death  in  fatal  cases  of  anthrax,  and  various  theories  have  been 
advanced  at  different  times  to  determine  this  point. 

In  the  most  virulent  form,  the  anthrax  acutissimus,  Bollinger  be- 
lieves that  the  rapid  growth  of  the  bacillus  in  the  blood  brings  about  a 
sudden  diminution  of  oxygen  and  a  surplus  of  carbonic  acid,  and  that 
death  takes  place  b}'  a  slow  process  of  asphyxia.  Against  this  theory 
it  can  be  maintained  that,  in  the  blood  of  animals  that  have  died  of  the 
acutest  form  of  the  disease,  comparatively  few  bacilli  are  found  ;  and, 
further,  that  in  the  experiments  made  by  Nencki,  on  the  blood  of  rabbits 
that  had  died  of  this  form  of  anthrax,  it  was  found  as  capable  of  oxy- 
genation as  the  blood  of  healthy  animals.     The  theory  that  death  results 


PATHOLOGY    AND    MORBID    ANATOMY.  583 

from  purely  mechanical  causes,  due  to  the  presence  of  bacilli  in  great 
abundance  in  the  blood-vessels,  is  likewise  not  tenable,  because  no  such 
fatal  degree  of  obstruction  in  the  capilhuy  circulation  has  been  found 
at  the  post-mortem  examinations.  As  a  third  hypothesis,  Bollinger 
advanced  that  the  bacillus  may  generate  a  cliemical  poison  that  may 
cause  death  by  intoxication.  In  refei'ence  to  the  last-mentioned  cause, 
Hotfa  calls  attention  to  the  following  three  possibilities  : — 

1.  The  bacilli  of  anthrax  are  in  themselves  poisonous,  and  the  in- 
crease in  their  number  increases  the  quantity  of  the  poison  in  the  same 
ratio.  Against  this  supposition  the  results  of  the  experiments  made  b}'' 
Hofl'a  himself  furnish  the  most  conclusive  proof.  Of  a  pure  culture  of 
anthrax  bacilli  he  injected  a  large  quantitj"  directly  into  the  jugular  veins 
of  rabbits.  The  animals  thus  infected  showed  no  symptoms  of  acute 
intoxication,  but  died  in  the  same  manner  as  animals  infected  in  the 
usual  wa^'. 

2.  The  bacilli  of  anthrax  produce  a  poison  capable  of  causing  fer- 
mentation in  the  blood  ;  this  poison  is  soluble  in  the  blood.  The  fact 
that  filtered  blood  of  animals  that  had  died  of  anthrax  did  not  produce 
toxic  symptoms  when  injected  into  health}'  animals  speaks  against  this 
argument. 

3.  The  bacillus  of  anthrax  separates  toxic  substances  from  complex 
combinations  in  the  organism.  This  last  explanation  appears,  from 
analogy  of  the  views  that  are  now  entertained  of  bacteria  and  ptomaines, 
to  be  the  most  plausible,  and  he  made  an  effort  to  produce  such  sub- 
stances outside  of  the  animal  body  upon  artificial  culture  media.  For 
this  purpose  he  cultivated  the  bacillus  with  the  greatest  precautions 
upon  sterilized  meat  kept  for  several  weeks  in  an  incul)ator  at  37^  C. 
(98.G°  F.).  The  chemical  product  thus  obtained  he  attenuated  according 
to  the  methods  advised  by  Stass-Otto,  Brieger,  and  after  the  more  recent 
method  of  Fischer. 

By  the  methods  of  Stass-Otto  and  Fischer  he  succeeded  in  pro- 
ducing a  substance  that  possessed  an  alkaline  reaction,  and  produced 
toxic  effects  in  animals.  A  strictlv-pure  article  and  an  accurate  chemical 
description  of  it  could  not  be  obtained,  on  account  of  the  smallness  of 
the  quantity  produced.  The  substance  produced  Iw  Stass-Otto's  method 
was  used  in  experimenting  on  frogs,  mice,  guinea-pigs,  and  rabbits  ;  both 
of  them  p>roduced  symptoms  of  intoxication.  After  a  short  period  of 
intoxication,  with  increased  action  of  the  heart  and  accelerated  respira- 
tion, the  animals  became  somnolent ;  respirations  deep,  slow,  and  irregu- 
lar, assisted  b}'  the  action  of  all  accessory  muscles  of  respiration  ;  pupils 
dilated,  temperature  normal,  diarrhoia,  faeces  bloody  ;  speedy  death.  At 
the  necropsy  the  heart  was  found  contracted,  the  blood  was  of  a  dark 


58i  PRINCIPLES   OF    SURGERY. 

color,  iuid  ecchymosis  of  the  pericardium  ami  peritoneum  existed.  There 
were  no  micro-organisms  in  the  blood.  The  pathological  conditions 
described  here  are  an  accurate  duplication  of  the  post-mortem  descrip- 
tion in  fatal  cases  of  anthrax.  The  same  author  succeeded  subsequently 
in  isolating,  by  a  complicated  process,  a  toxic  substance  from  the  bodies 
of  anthracic  rabbits  with  the  formula  CgH^Xg,  which  he  called  ardhracin, 
besides  a  small  quantity  of  methylguanidin.  To  the  former  substance 
he  attributes  the  toxic  symptoms  in  cases  of  anthrax.  Injected  subcu- 
taneousl}'  in  rabbits,  it  produced  first  restlessness,  rapid  pulse,  and 
accelerated  respiration, followed  hy  somnolence,  deeper  and  slower  respi- 
ration, diarrhoea,  asphyictic  symptoms,  convulsions,  and  death.  This 
substance  is  closely  allied  to  kreatin,  and  contains  23  per  cent,  of 
nitrogen.  These  experiments  leaA'e  but  little  doubt  that  the  fatal  termi- 
nation in  cases  of  anthrax  is  caused  b}'  the  action  of  toxic  ptomaines 
formed  in  the  bod}'  in  consequence  of  the  action  of  the  bacilli  upon 
certain  as  3'et  unknown  combinations  in  the  organism. 

DIFFERENTIAL  DIAGNOSIS. 
Anthrax  must  be  distinguished  from  other  forms  of  acute  circum- 
scribed inflammation,  notably  from  furuncle  and  carbuncle.  A  furuncle 
is  conical  from  the  beginning,  and  the  summit  is  transformed  into  a 
small  slough.  A  carbuncle  is  nothing  more  nor  less  than  a  multiple 
furuncle,  and  is  produced  by  the  same  microbic  cause.  Antlirax  develops 
from  a  single  centre,  and  the  infiltration  proceeds  from  tliis  point  in  all 
directions.  Necrosis  is  preceded  b}-  vesication,  and  the  black,  necrosed 
tissue  is  fully  exposed  after  exfoliation  of  the  epidermis.  The  oedema- 
tous  form  of  anthrax  might  be  mistaken  for  erysipelas  or  acute  phlegmo- 
nous inflammation.  Anthrax  oedema  is  usually  not  attended  by  much 
discoloration  of  the  skin,  and  there  is  no  such  distinct  and  abrupt  line  of 
limitation  as  in  erysipelas.  Phlegmonous  inflammation,  when  advanced 
to  the  extent  where  it  ma}'  resemble  anthrax  cedema,  has  gone  on  to  the 
stage  of  suppuration.  The  differential  diagnosis  between  malignant 
oedema  and  anthrax  can  only  be  made  by  searching  for  the  primary  cause 
by  the  use  of  the  microscope.  A  positive  differential  diagnosis  between 
suppurative  lesions  and  anthrax  can  be  made  in  the  course  of  one  or  two 
days  by  inoculation  experiments.  If  a  rabbit  or  mouse  is  infected  with 
a  drop  of  antliracic  blood  or  serum  taken  from  the  centre  of  the  inflam- 
matory product,  death  from  anthrax  will  follow  within  two  days;  while 
the  same  amount  of  fluid  taken  from  a  suppurative  depot  will  produce 
no  effect,  or,  at  most,  only  a  circumscribed  abscess.  As  the  anthrax 
bacillus  can  be  readily  stained  and  identified  under  tlie  microscope,  a 
positive  differential  diagnosis  between  these  aflections  can  always  be 
made  by  the  use  of  the  microscope. 


PROGNOSIS.  585 

PROGNOSIS. 
The  location  of  the  disease,  the  character  of  the  tissues  primarily 
affected,  and  the  general  condition  of  the  patient  greatly  influence  the 
prognosis  in  cases  of  anthrax.  The  prognosis  is  most  favorable  in  3'oung, 
health^'  individuals  sutieriiig  from  authracic  pustule,  as  in  sucli  instances 
the  general  strength  of  the  patient  and  the  active  tissue  proliferation  at 
the  seat  of  infection  are  well  calculated  to  prevent  general  infection  ; 
while,  in  persons  debilitated  from  any  cause  affected  with  the  oedematous 
variety,  general  infection  is  very  liable  to  follow.  An  anthrax  oedema 
of  the  hand  or  arm  is  a  less  serious  condition  than  a  similar  affection  of 
the  lace  or  neck.  Asa  general  rule,  it  may  be  stated  that,  the  firmer  and 
more  circumscribed  the  local  lesion,  the  more  favorable  the  prognosis, 
and,  vice  vei'sd,  the  more  extensive  the  area  of  infection  and  the  more 
diffuse  the  oedema,  the  greater  the  danger  to  life  from  general  infection. 
The  occurrence  of  general  infection  may  be  recognized  without  difficult}' 
by  the  general  symptoms  which  indicate  the  existence  of  progressive 
septic  infection.  The  bacillus  of  anthrax  multiplies  with  great  rapidity 
after  its  entrance  into  the  circulation,  and  the  anthracin,  which  produces 
the  septic  symptoms,  is  elaborated  in  amounts  proportionate  to  the 
number  of  bacilli  in  the  body.  Fever,  cough,  rapid  respiration,  feeble  and 
rapid  pulse,  diarrhoea,  and  delirium  are  some  of  the  symptoms  indicating 
that  the  disease  has  become  general.  All  hope  of  recovery  must  be 
abandoned  as  soon  as  general  infection  has  occurred  ;  death  from  pro- 
gressive infection  and  intoxication  will  be  certain  to  take  place,  in  spite 
of  the  most  heroic  local  and  general  treatment. 

TREATMENT. 

The  surgical  treatment  of  anthrax  must  be  directed  toward  the 
elimination  or  neutralization  of  the  primary  microl)ic  cause.  As  within 
the  living  bod}'  the  reproduction  of  the  primary  cause  takes  place  ex- 
clusively by  segmentation  of  the  bacilli,  any  germicidal  agents  that 
inhibit  or  destroy  the  pathogenic  property  of  the  bacilli  will  be  found 
useful  in  the  local  treatment  of  anthrax.  It  has  been  found  experiment- 
all}'  that  a  5-per-cent.  solution  of  carbolic  acid  will  arrest  the  growth 
of  anthrax  cultures,  and  clinical  experience  has  demonstrated  that  the 
same  solution,  when  brought  in  contact  with  the  infected  tissues  by 
parenchymatous  injections,  has  a  decided  influence  in  arresting  further 
extension  of  the  infection. 

Lande  reports  2  cases  of  malignant  antlirax  saved  by  parenchj^ma- 
tous  injections  of  carbolic  acid.  In  the  first  case,  a  man  aged  27,  the 
npi)C'V  lip  was  the  seat  of  the  disease;  in  the  second,  a  woman  aged  65, 
the  anthrax  occupied  the  region  below  the  scapula.     Both  patients  were 


586  PRINCIPLES   (jy   SUKGEKi'. 

very  ill,  low  delirium  and  other  symptoms  of  toxsemia  being  present. 
The  injections  were  made  into  the  subcutaneous  tissue  around  the 
pustule.  The  strongest  solution  used  consisted  of  15  grammes  of 
neutral  glycerin  and  an  equal  part  of  distilled  water,  in  which  3  grammes 
of  pure  carbolic  acid  were  dissolved.  The  injections  were  made  at  five 
points  around  the  pustule,  and  represented  a  total  dose  of  50  centi- 
grammes of  the  acid.  The  injections  caused  considerable  pain,  but 
rapid  improvement  followed.  The  solution  used — 10  per  cent. — was 
stronger  than  any  previously  employed  for  the  same  purpose  by  Bojckel, 
Raimbert,  and  others.  A  5-per-cent.  solution  in  ordinary  cases  is  strong 
enough,  but  in  grave  cases  the  10-per-cent.  solution  must  be  used  until 
improvement  takes  place,  which  should  occur  within  fort^'-eight  hours. 
The  object  of  the  parench^'matous  injections  should  be  to  saturate,  as 
far  as  possible,  all  of  the  infected  tissues  with  the  antiseptic  for  the 
purpose  of  destroying  the  bacilli,  and,  at  the  same  time,  to  permeate  the 
surrounding  healthy  tissue  for  some  distance,  with  a  view  of  destroying 
the  soil  for  the  growth  of  the  microbes  in  advance  of  the  invasion. 
The  surface  over  the  entire  infected  area  should  be  rendered  thoroughly 
aseptic,  in  order  to  prevent  secondar3'  infection  with  pus-microbes 
through  the  needle-punctures.  The  punctures  should  be  made  a  few 
lines  from  the  border  of  infiltration,  but  always  toward  the  centre  of  the 
infected  district.  The  injection  is  made  gradually  as  the  needle  is  with- 
drawn, so  as  to  saturate  the  tissues  for  some  distance  along  the  entire 
length  of  the  track  of  the  needle.  At  one  sitting  from  four  to  twelve 
injections  are  made,  according  to  the  size  of  the  anthrax  and  the  urgenc}'' 
of  the  symptoms.  A  compress  wrung  out  of  a  1-to-lOOO  solution  of 
corrosive  sublimate  should  be  kept  constantl}'  applied.  Application  of 
an  ice-bag  over  the  antiseptic  compress  will  assist  the  germicidal  agents 
in  retarding  or  arresting  further  multiplication  of  the  bacilli  in  the 
tissues.  The  injections  should  be  repeated  every  six  hours  until  the 
disease  is  under  control,  or  until  it  is  deemed  unsafe,  from  the  quantity 
injected,  to  administer  more  carbolic  acid  for  fear  of  causing  intoxica- 
tion. Excision  has  been  objected  to  on  the  ground  that  the  wound 
might  become  a  new  source  of  infection,  and  thus  leave  the  patient  in  a 
more  precarious  condition,  so  far  as  general  infection  is  concerned,  than 
l^efore  the  oi)eration  ;  but  such  is  not  the  case  if  the  ai'ea  of  infection  is 
limited  and  the  incisions  can  be  made  through  healthy  tissue.  The 
following  case  affords  a  good  illustration  of  the  value  of  excision  of 
anthrax  in  well-selected  cases. 

Kaloff,  of  St.  Petersburg,  in  making  experiments  with  anthrax  on 
animals,  accidentally^  infected  himself,  either  by  a  needle-puncture  or  by 
handling  the  organs  of  anthracic  animals.     The  local  infection  appeai*ed 


TREATMENT.  587 

on  the  outer  side  of  the  thumb  of  the  left  hand  as  a  small  vesicle,  that 
soon  disappeared,  but  gave  place  to  circumscribed  infiltration  on  the 
second  daj-.  This  inflammation  rapidly  extended,  and  was  surrounded 
with  haemorrhagic  vesicles.  The  indurated  tissues  were  promptlj- 
removed  by  excision;  nevertheless,  on  the  next  da}-,  swelling  of  axillary 
glands  on  same  side,  fever,  great  prostration,  also  diarrhoea,  set  in. 
The  skin  in  the  axillary  region  and  side  of  chest  was  much  swollen,  and 
at  different  points  bright-red,  at  others  bluish-red.  One  of  the  axiliary 
glands,  the  size  of  a  hen's  egg,  and  glands  along  the  margins  of  the 
pectoralis  major  muscle  were  removed,  and  field  of  operation  thoroughly 
disinfected  with  a  5-per-cent.  solution  of  carbolic  acid  ;  the  same  solu- 
tion was  also  thrown  into  the  surrounding  tissues  with  a  hypodermic 
springe.  Cessation  of  fever  and  rapid  healing  of  wound,  followed  bj' 
recover}'.  The  diagnosis  was  confirmed  by  successful  cultivations  made 
with  fragments  of  the  excised  tissue  in  bouillon  and  gelatin.  Excision 
should  always  be  resorted  to  in  cases  of  anthrax  pustule,  as  it  fulfills 
the  etiological  indications  more  promptly  and  thoroughlj-  than  anj-  other 
treatment.  The  incisions  should  be  made  outside  of  the  indurated 
tissues,  and,  for  the  purpose  of  preventing  traumatic  dissemination  of 
the  disease,  the  surface,  after  thorough  irrigation,  should  be  brushed 
over  with  a  10-per-cent.  solution  of  carbolic  acid  before  the  wound  is 
sutured.  This  procedure  will  destro}^  any  bacilli  that  may  have  become 
deposited  upon  the  surfoce  of  the  wound. 

In  the  case  just  cited  it  is  possible  that  lymphatic  infection — an 
unusual  occurrence  in  anthrax — developed  in  consequence  of  the  entrance 
of  bacilli  into  the  open  lymphatic  vessels  on  the  surface  of  the  wound. 
Excision  under  strict  antiseptic  precautions  is  also  justifiable  in  anthrax 
(edema,  even  if  all  of  the  infected  tissues  cannot  be  removed,  as  sterili- 
zation of  the  remaining  portion  of  the  infected  tissues  can  be  secui'ed 
^•ubsequently  more  efficiently  by  parenclnmatous  injections  than  if  the 
primary  focus  of  infection  is  allowed  to  remain  as  a  hot-bed  for  pro- 
gressive infection.  In  such  cases  it  would  be  good  practice  to  sear  the 
whole  surface  of  the  wound  with  the  actual  cautery,  for  the  purpose  of 
preventing  general  and  regional  dissemination  by  the  entrance  of  bacilli 
into  the  open  luraiua  of  veins  and  lymphatics,  and  also  to  increase  the 
resisting  capacity-  of  the  tissues  to  infection  by  exciting  an  active  tissue 
proliferation.  Tiie  actual  cautery  would  prove  successful  in  recent  cases, 
in  cutting  short  an  attack,  if  resorted  to  before  any  considerable  infiltra- 
tion has  occurred.  It  is  said  that  shepherds,  in  districts  where  anthrax 
is  endemic,  destroy  the  vesicle  with  a  red-hot  needle  as  soon  as  it  is 
detected,  and  it  is  seldom  that  the  infection  does  not  yield  to  this  treat- 
ment.    At  this  early  stage  the  wdiole  area  of  infection  is  limited,  and 


588  PRINCIPLES   OF    SUUGERY. 

coiilil  be  most  effectutiUy  destroyed  with  the  sharp  point  of  a  Paquelin 
canter}'.  The  general  symptoms  in  severe  cases  of  local  anthrax,  and 
after  general  infection  has  occurred,  resemble  the  clinical  aspects  of 
septicaemia  produced  by  other  causes,  and  patients  suffering  from  general 
primary  or  secondary  anthrax  require  the  same  stimulating,  tonic,  and 
supporting  treatment  that  has  been  laid  down  in  the  treatment  of 
septicaemia. 


CHAPTER  XXIV. 

Glanders. 

Synonyms:  Farcy;  equinia;  malleus  humidus ;  Morve ;  Rotzkrank- 
heit.  A  contagious  disease  characterized  by  multiple  foci  of  inflamma- 
tion and  suppuration,  and  caused  by  infection  with  a  specific  microbe, — 
the  bacillus  mallei.  The  disease  originates  in  the  horse  and  occurs  in 
men  by  contagion.  Although  glanders  in  man  is  a  rare  affection,  it  pre- 
sents, from  a  bacteriological  stud}^,  so  many  points  of  interest  that  it 
merits  more  than  a  passing  notice.  It  is  one  of  the  infectious  diseases 
whose  microbic  cause  is  now  thoroughly  understood. 

BACTERIOLOGICAL   HISTORY   OF   THE   DISEASE. 

That  glanders  in  man  occurred  as  an  infection  from  the  horse  species 
of  animals  has  been  known  for  a  long  time.  Its  contagiousness  among 
horses  was  asserted  by  Sollegsel  in  the  seventeenth  century.  Rindfleisch 
believed  that  he  saw  vibriones  in  the  granular  contents  of  glanderous 
abscesses.  Klebs  detected,  in  cultures  of  pus  taken  from  animals  suffering 
from  this  disease,  small  rods  and  grannies,  but  further  cultivations  and 
inoculations  in  rabbits  failed.  The  presence  of  minute  organisms  in 
cases  of  glanders  was  pointed  out  by  Christatt  and  Kiener  in  1868,  and 
their  observations  were  corroborated  by  Bouchard,  Capitan,  and  Charrin, 
who  found  the  organisms  not  only  in  parts  exposed  to  the  air,  such  as 
nasal  ulcerations  and  pulmonar}'^  abscesses,  but  also  in  parts  not  so 
exposed,  such  as  the  spleen,  liver,  and  lymphatic  glands.  Cliaveau 
demonstrated  bj'  his  experiments  that  the  virus  of  glanders  was  fixed  to 
small,  solid  particles,  as  he  found  the  sediment,  which  formed  after  di- 
lating pus  with  water,  active.  This  discover}'  marked  an  advance  in  the 
knowledge  of  the  ph3'sical  nature  of  the  virus.  Loffler  and  Schiitz  are 
the  discoverers  of  the  bacillus  of  glanders  in  horses.  In  1882  they  made 
a  preliminary  report  of  their  researches  (Deutsche  Med.  Wochenschrift, 
1882,  No.  52).  In  188fi  Lotfler  published  his  elaborate  monograph  on 
this  subject  ("Die  ^tiologie  der  Rotzkrankheit,"  Arheiten  aus  devi 
Kaiserlichen  Gesundheitsamte  zii  Berlin,  Bd.  i,  pp.  141-199).  About 
the  same  time,  0.  Israel  made  cultures  upon  blood-serum  from  nodules 
of  three  glanderous  horses,  with  which  he  produced  the  disease  artificially 
in  rabbits.     The  bacilli  contained  in  these  cultures  correspond  with  the 

(589) 


590  PRINCIPLES    OF    SURGERY. 

description  of  those  isolated  by  Sehiitz  and  Loffler.  Soon  after  Loffler's 
first  paper  appeared,  Bouchard,  Capitan,  and  Charrin  published  almost 
simultaneously  the  results  of  their  researches  and  observations;  but  it 
appears  from  Loffler's  second  paper  that  none  of  them  had  been  able  to 
produce  a  pure  culture.  Kitt  and  Weichselbaum  were  the  first  who,  by 
their  own  investigations,  were  able  to  corroborate  the  correctness  of 
Loffler's  discovery  :  the  former  by  his  observations  and  experiments  on 
animals,  the  latter  b}'  a  case  of  glanders  in  the  human  subject  that  came 
under  his  own  observation. 

DESCRIPTION  OF  BACILLUS  MALLEI. 
According  to  Loffler,  the  bacillus  of  glanders  appears  as  a  small  rod, 
which  is  somewhat  shorter  and  broader  than  the  tubercle  bacillus ;  its 
length  varies  but  little,  and  corresponds  to  about  two-thirds  of  the  di- 
ameter of  a  red  blood-corpuscle  ;  the  thickness  varies  between  one-fifth 
and  one-eighth  of  its  length. 

These  bacilli  are  either  straight  or  slightly  curved  and  rounded  at 
'^V/\''\\i\K-^TTrt  their  ends.  Usually,  they  are  found  in  pairs  in  a 
^//y^\^\(<^/,'y^{'\  parallel  direction,  held  together  by  a  delicate,  unstained 
M^^^t^^/^ri^^h  pellicle.  Examined  in  a  drop  of  fluid,  they  show  active 
l^\//l^^\|l\\y^A)j  molecular  movements.  Spontaneous  movements  could 
Fig.  107.— Bacilli  ^'^t  be  observed  by  Loffler.  The  colorless  and  some- 
^^v^T^^Si^'^'til^.^?.^     times  even  somewhat  dilated  portions   of  the  stained 

A     xOUNG      x^OIAlU  I 

^Baumgarten  )^  ^'''^'  hacillus  are  not  spores,  but,  as  Loffler  affirms,  indica- 
tions of  commencing  death.  Loffler  found  that  bacilli 
kept  in  a  dry  state  for  three  months  could  occasionally  be  made  to 
grow,  but  in  most  instances,  after  a  few  weeks,  tlie}^  could  no  longer  be 
cultivated,  which  fact  speaks  against  the  existence  of  spores.  On  the 
other  hand,  in  favor  of  the  presence  of  endo-spores  must  be  regarded  the 
results  obtained  by  Rosenthal,  in  Baumgai'ten's  laboratory,  with  Neisser's 
method  of  staining  spores,  who  showed  that  at  least  some  of  the  bacilli 
contain  spores,  while  in  others  the  points  which  refuse  staining  material 
are  undoubtedly,  as  Loffler  claims,  evidences  of  vacuolar  degeneration. 

(a)  Staining. — The  method  of  staining  the  bacilli  of  glanders  is 
characteristic  ;  when  the  bacilli  are  treated  b}^  basic  and  aniline  dyes  no 
effect  is  produced. 

Method  of  Schutz. — The  sections  are  placed  for  twenty-four  hours 
in  the  following  mixture:  Potash  solution  (1  in  10,000),  concentrated 
alcohol,  methylene-blue  solution, — equal  parts.  Wash  the  sections  in  a 
watch-glass  with  water  acidulated  with  4  drops  of  acetic  acid.  Transfer 
for  five  minutes  to  50-per-cent.  alcohol,  clarify  in  clove-oil,  and  mount  in 
Canada  balsam. 


TENACITY    OF    BACILLUS    MALLEI.  591 

Lbffler's  Method. — Sections  are  immersed  for  a  few  minutes  in  a 
solution  of  potasli  (1  in  10,000),  then  for  a  few  minutes  in  an  alkaline 
solution  of  methyl-blue  ;  after  which  they  are  decolorized  with  a  solution 
of  tropseolin  in  acetic  acid,  or,  what  is  still  better,  in  a  fluid  composed 
of  10  centimetres  of  distilled  water,  2  drops  of  sulphuric  acid,  and  1 
drop  of  a  5-per-cent.  solution  of  oxalic  acid. 

(b)  Cultivation. — When  cultivated  on  solid  sterilized  blood-serum  at 
a  temperature  of  38°  C.  (100.4°  F.),  the  growth  appears  in  the  form  of 
minute  transparent  drops  on  the  surface,  which  consist  exclusively  of  the 
characteristic  bacilli.  Cultures  upon  boiled  potato,  according  to  Loffler, 
Kitt,  and  Weichselbaum,  form  in  three  days  a  uniform  amber-yellow 
layer,  that  about  the  sixth  to  the  eighth  day  assumes  a  reddish  hue,  resem- 
bling the  color  of  oxide  of  copper,  which  is  not  easih'  mistaken  for  any 
other  culture  upon  the  same  soil.  Upon  this  nutrient  medium  the  bacilli 
were  cultivated  through  twelve  generations,  and  the  cultures  retained 
their  activit}'  for  a  3'ear  ;  whether  the  bacillus  was  capable  of  cultivation 
after  this  time  is  not  mentioned.  The  temperature  at  which  cultures  could 
be  made  to  grow  varied  from  30°  to  40°  C,  (86°  to  104°  F.).  The  bacillus 
also  grows  in  neutralized  bouillon,  with  and  without  the  addition  of  pep- 
tone. The  culture  first  renders  the  fluid  turliid,  and,  later,  settles  on  the 
bottom  of  the  vessel  as  a  white,  shining  mass.  Weichselbaum  succeeded 
in  growing  the  bacillus  upon  ordinary  nutrient  agar  and  gelatin.  Ras- 
kina  rendered  these  nutrient  media  more  fertile  for  the  growth  of  this 
microbe  by  the  addition  of  chicken-natron  albuminate.  Kranzfeld  suc- 
ceeded best  with  Nocard  and  Roux's  mixture, — meat-peptone,  glycerin, 
agar-agar. 

TENACITY    OF   BACILLUS   MALLEI. 

Loffler  ascertained  that  this  bacillus  shows  the  same  degree  of  re- 
sistance to  heat  and  germicidal  substances  as  other  bacilli  without  spores. 
The  bacillus  is  destroyed  b}-  exposure  for  ten  minutes  to  a  temperature 
of  55°  C.  (131°  F.).  It  is  also  destroyed  by  a  3-  to  5-per-cent.  solution 
of  carbolic  acid  in  five  minutes,  and  in  two  minutes  in  a  l-to-5000  solu- 
tion of  corrosive  sublimate. 

INOCULATION    EXPERIMENTS. 

Kitt  enumerates  the  following  animals  as  being  susceptible  of  inocu- 
lation with  the  A'irus  of  glanders  :  Tiger,  lion,  cat,  sheep,  goats,  guinea- 
pigs,  horse,  ass,  rabbits,  and  white  rat.  Pigs,  dogs,  the  common  rat, 
ducks,  and  chickens  possess  great  immunity  ;  the  inoculations  at  best 
produce  only  a  slight  local  reaction.  Loflfler  made  his  first  experiments 
on  guinea-pigs  and  the  field-mouse.  In  the  guinea-pigs  he  observed, 
three  to  five  days  after  subcutaneous  injection  of  a  pure  culture,  an  ulcer 


592  PRINCIPLES   OF    SUF^GERY. 

Jit  the  point  of  inoculation,  and  at  the  end  of  the  first  week  swelling  of 
the  nearest  lymphatic  glands,  attended  by  suppuration.  At  this  stage 
of  the  disease  the  process  often  came  to  a  stand-still  and  the  animals 
recovered.  In  man}-  animals  the  disease  progressed  quite  rapidly  to  a 
fatal  termination.  Abscesses  were  frequently  found  in  the  testicle  and 
the  epididymis  in  the  male,  and  in  the  breast  and  external  genital  organs 
of  the  female.  The  face,  nasal  cavity,  and  ankle-joint  were  also  fre- 
quently the  seat  of  ulcerative  processes.     In  case  the  disease  proved 


V3 


©. . 


Dc^-^^'^Q  '"^''^'i  "'"^.Vs  '^''^''^O        "^  "    "      >.  ,,       *-  . 


Fig.  108.— Glanderous  Nodule  from  the  Liver  of  a  Field-Mouse. 
Bismarck-Brown  Staining.  Bacilli  Stained  after  Loffler's 
Method.  Bacilli  Magnified  and  Drawn  Twice  this  Size.  x250. 
{Baumgarten.) 

K,  karyokinetic  figures  ia  epithelioid  cells. 

fatal,  death  usually  occurred  three  or  four  weeks  after  inoculation.  At 
the  post-mortem,  aside  of  the  affections  enumerated,  nodules  were  found 
in  the  spleen,  lungs,  and  frequently  in  the  liver.  The  histological  struc- 
ture of  a  recent  nodule  bears  a  great  resemblance  to  tubercle.  The 
bacilli  are  always  found  more  numerous  in  the  nodules  if  the  disease  is 
produced  artificially'^  bj'  inoculation.  The  inflammatory  product  is  first 
composed  almost  exclusively  of  epithelioid  cells,  between  which  leuco- 
cytes from  the  periphery  insinuate  themselves.     Giant  cells  are  never 


INOCULATION    EXPERIMENTS.  593 

fuund  ill  glanderous  nodules;  the  epithelioid  cells  are  derivatives  of  con- 
nective tissue  and  endothelial  cells ;  while  the  leucocytes  escape  from  the 
inflamed  capillary  vessels.  Baumgarten  constantly  observed  karyokinetic 
figures  in  the  epithelioid  cells. 

The  leucocytes  that  enter  the  nodule  soon  show  evidences  of  frag- 
mentation, and  are  converted  into  pus-corpuscles.  The  bacilli  are  dis- 
tributed among  the  cellular  elements  singly,  in  pairs,  and  in  groups. 
Some  of  them  may  be  seen  also  within  tlie  cellular  elements,  especiallj'^ 
the  epithelioid  cells. 

Field-mice  proved  a  great  deal  more  susceptible  to  the  virus  of 
glanders  tlian  guinea-pigs,  as  they  usually  died  three  or  four  da^'S  after 
inoculation.  The  necropsy  in  these  niiimals  showed,  at  the  point  of 
inoculation,  an  infiltration  from  which  swollen  Ij'inphatic  vessels  led  to 
the  nearest  lymphatic  glands.  In  the  spleen  and  liver,  which  were  always 
found  greatly  enlarged,  numerous  small  nodules  could  be  seen,  while  the 
remaining  internal  organs  presented  a  normal  appearance.  Glanders  in 
guinea-pigs  and  field-mice  presents  a  series  of  pathological  changes  that 
cannot  be  mistaken  for  any  other  aftection.  The  bacilli  of  glanders  in 
the  different  organs  can  be  detected  most  readily  in  recent  specimens. 
In  the  blood  bacilli  were  detected  onl3'  in  very  acute  cases, — a  circum- 
stance that  explains  wh}'  so  man}'  inoculations  with  the  blood  of  glan- 
derous horses  proved  unsuccessful.  The  bacilli  of  glanders  are  evidently 
strictly  tissue-  and  not  blood-  parasites. 

Lundgren  took  a  nodule  from  the  lungs  of  a  horse  that  had  died  of 
glanders,  and  implanted  fragments  of  it  under  the  skin  of  rabbits.  The 
animals  died  about  the  nineteenth  da}'  after  inoculation,  and  the  necropsy 
revealed  induration  and  small  abscesses  at  the  point  of  infection,  and 
small,  yellow  nodules  in  the  spleen,  liver,  lungs,  testicles,  and  mucous 
membrane  of  the  nose.  Implantation  of  spleen-tissue  into  other  rabbits 
fi^ed  the  period  of  incubation  in  this  animal  at  from  eleven  to  twelve 
days. 

Kranzfeld  has  recently  published  the  results  he  obtained  by  inocula- 
tions with  the  virus  of  glanders  in  an  animal  hitherto  not  subjected  to 
experimentation  of  this  kind.  He  procured  a  pure  culture  from  a  nodule 
of  a  man  who  had  died  of  glanders  after  a  brief  illness.  Inoculations 
were  made  in  a  small  rodent  which  is  veiy  numerous  in  the  southern 
])art  of  Russia,  the  Spermophilus  guttatus.  The  course  of  the  disease  in 
this  animal  was  almost  the  same  as  in  the  field-mice  that  were  used  by 
Loffler.  Of  28  animals  infected  with  different  cultures,  16  died  on  the 
fourth  day,  9  on  the  fifth,  2  on  the  seventh,  and  1  on  the  tenth.  The 
post-mortem  appearances  were  always  characteristic  :  a  greenish-gray 
infiltration  at  the  point  of  inoculation  and  a  number  of  nodules  in  the 

38 


594  PRINCIPLES   OF    SURGERt. 

spleen  ;  in  one  animal  also  ver^'  small,  white  nodnles  in  the  liver.  Culti- 
vations from  these  nodules  yielded  a  pure  growth  of  the  bacillus  of 
glanders.  If  animals  are  infected  by  direct  injection  of  a  pure  culture 
into  a  vein,  no  serious  symi)toms  are  produced  ;  but,  if  soon  thereafter 
one  or  more  muscles  are  injured  subcutaneously,  the  microbes  escape 
through  the  lacerated  vessels,  localize  at  the  seat  of  injury,  and  produce 
a  grave  form  of  the  disease.  It  has  been  determined  by  experiment  that 
the  farther  from  the  trunk  the  inoculations  are  made,  the  less  intense  is 
the  local  reaction.  When  an  animal  is  inoculated  at  a  distance  from  the 
trunk,  and  shows  no  general  symj^toms,  a  subcutaneous  injury  of  any 
portion  of  the  trunk  will  furnish  the  necessary  conditions  for  the 
development  of  a  local  form  of  infection. 

It  had  been  generally  believed  that  the  intact  skin  furnished  an 
adequate  protection  against  infection  with  the  bacillus  of  glanders  until 
shown  very  recently  by  the  experiments  of  Babds  and  Nocard  that  infec- 
tion can  take  place  through  the  healthy  skin.  Nocard  rubbed  a  pure 
culture  of  the  bacillus  into  the  skin  in  two  guinea-pigs,  and  found  on  the 
fifteenth  daj'  some  of  the  hair-follicles  the  seat  of  glanderous  inflamma- 
tion. Histological  examination  showed  numerous  bacilli  in  the  follicles, 
the  epithelial  la^-er  much  thickened,  and  tlie  surrounding  connective 
tissue  in  a  state  of  proliferation.  The  infection  had  extended  from  the 
follicles  through  the  connective  tissues  into  the  lymphatic  vessels 
underneath,  as  was  evident  from  the  presence  of  bacilli  in  the  lymphatic 
glands,  vessels,  and  connective-tissue  spaces  in  the  immediate  vicinity 
of  the  primary  lesion  of  the  skin. 

GLANDERS   IN    THE    HORSE. 

Glanders  and  furc}'  in  the  horse  are  different  manifestations  of  the 
same  disease,  and,  as  each  of  them  is  divided  into  an  acute  and  chronic 
form,  we  find  described  four  varieties  of  the  disease  in  this  animal, — 
acute  and  chronic  glanders,  acute  and  chronic  fare}'. 

Acute  Glanders. — This  form  of  glanders  is  attended  by  a  high  tem- 
perature (106^  to  109°  F.)  and  other  symptoms  of  acute  sepsis,  and 
proves  uniformly  fatal  in  a  few  da3-s.  The  breathing  is  accelerated,  the 
pulse  feeble  and  rapid,  and  there  is  complete  loss  of  appetite.  The  nasal 
mucous  membrane,  at  first  of  a  dark,  copper}'  color,  with  dark-red  ecclij'- 
motic  patches,  becomes  purple  ;  these  ecch^-moses  are  rapidh'  converted 
into  ulcers,  from  which  issues  a  copious  sero-sanguinolent  discharge. 
Lymphatic  infection  is  a  characteristic  feature  of  acute  glandei'S.  The 
submaxillary  and  cervical  glands  enlarge  and  suppurate,  discharging 
unhealthy-looking,  ichoi'ous  pus.  Abscesses  also  form  in  the  Ij-mphatics 
of  the  face. 


GLANDERS  IN  THE  HORSE.  595 

Chronic  Glanders. — This  is  the  form  most  commonly  seen  in  the 
horse.  The  disease  begins  in  the  mucons  membrane  of  the  nose.  Small, 
whitish  nodnles,  composed  of  small,  round  cells,  are  formed  in  the 
mucous  membrane.  These  nodules  soften  and  ulcerate.  Similar  nodules 
may  be  found  in  the  larynx,  trachea,  and  bronchi.  The  ulcerations  may 
remain  superficial,  or  they  ma}'  extend  to  the  deep  tissues,  even  attacking 
cartilage  and  bone.  The  internal  organs,  especially  the  lungs,  may 
become  the  seat  of  metastatic  foci.  The  left  nostril  appears  to  be 
affected  more  frequentl}^  than  the  right.  The  h'mphatic  glands  under- 
neath the  lower  jaw  enlarge  A'erj^  rapidly,  often  reaching  considerable 
dimensions  during  a  single  night.  The  glandular  swellings  may  continue 
for  several  days,  afterward  slowl}^  disappear,  and  then  re-appear  as 
rapidly  as  before.  The  discharge  from  the  nostrils  presents  a  starchy 
or  glue-like  appearance,  adheres  to  the  mucous  membrane,  where  it  dries 
and  accumulates,  causing  narrowing  of  the  nasal  opening. 

Acute  Farcy. — Acute  farcy,  together  with  chronic  farc}^  is  simply 
another  manifestation  of  glanders,  and  is  initiated  in  a  verj'  similar 
manner  to  acute  glanders.  There  are  the  same  lesions  of  the  Ij-mphatics 
and  nodules,  and  abscesses  are  found  in  the  skin.  A  general  swelling  of 
the  cutaneous  tissues  takes  place,  varj'ing  in  size  for  a  time,  but  suddenh' 
a  number  of  distinct  swellings  or  nodules  will  appear,  termed  "  farc\' 
buds."  These  specific  nodules,  so  characteristic  of  farc}-  in  either  its 
acute  or  chronic  form,  involve  the  skin,  subcutaneous  connective  tissue, 
or  they  ma}^  extend  to  the  deeper  tissues.  The}'  var}-  in  size  from  a  pea 
to  a  hazel-nut.  These  nodules  suppurate,  and,  after  evacuation  of  their 
contents,  leave  ragged  ulcers  that  discharge  a  foul,  graj^ish-white,  cream}' 
liquid  tinged  with  blood.  When  several  ulcers  are  in  close  proximity 
tliey  may  become  confluent  and  form  an  extensive  ulcerating  surface. 
With  the  appearance  of  the  nodules  the  lymphatics  become  inflamed, 
swollen,  and  indurated.  Not  infrequently  acute  farcy  terminates  in  tlie 
development  of  acute  glanders,  with  all  the  pathological  conditions  that 
have  been  described  as  characteristic  of  that  disease,  thus  showing  their 
etiological  identity. 

Chronic  Farcy. — In  this  form  of  glanders  the  lymphatic  glands  are 
princii):illy  involved.  The  disease  is  not  attended  by  much  febrile  dis- 
turbance, and  all  of  the  other  general  symptoms  are  less  marked  than  in 
the  other  varieties  of  glanders.  The  lymphatic  glands  become  enlarged, 
and  nodules  are  formed  in  the  skin,  lungs,  and  other  viscera.  Central 
softening  and  suppuration  of  the  nodules  is  a  regular  occurrence.  Long, 
fistulous  tracts  often  result  from  extensive  undermining  of  the  skin.  In 
all  of  these  different  forms  of  glanders  in  the  horse  the  cause  remains 
the  same,  and  the  pathological  conditions  are  identical;  only  the  clinical 


596  PRINCIPLKS    OF    SURGERY. 

aspects  vary  from  the   location,   intensity,  and  extent  of  the  primary 
infection. 

GLANDERS   IN   MAN. 

In  man  the  disease  occurs  in  an  acute  and  chronic  form,  but  does 
not  exactly  resembe  any  of  the  varieties  of  the  disease  in  the  horse  or 
the  disease  artificially  produced  in  animals  by  inoculation.  The  discharge 
from  the  nostrils  of  a  diseased  horse,  brought  in  contact  with  an  abraded 
surface  or  a  mucous  membrane,  will  communicate  the  disease.  Notwitli- 
standing  the  positive  results  that  followed  the  cutaneous  inoculations 
in  guinea-pigs  with  a  pure  culture  of  the  bacilli  of  glanders  by  Nocard, 
it  is,  for  all  practical  purposes,  safe  to  make  the  assertion  that  the  virus 
of  glanders  can  only  find  entrance  into  the  organism  through  a  wounded 
surface.  Whether  infection  may  not  take  place  through  the  alimentar}- 
canal  has,  so  far,  not  been  definitel}^  ascertained.  It  is  certain  that  the 
disease  cannot  be  contracted  bj'  eating  boiled  or  fried  flesh  of  animals. 
Infection  through  the  respiratory  organs  is  possible,  as  cases  have  been 
reported  in  which  the  lungs  were  the  primary  and  only  seat  of  the  dis- 
ease. The  fact  that  man  can  be  infected  with  a  pure  culture  of  the  bacilli 
of  glanders  as  successfully  as  the  animals  that  have  been  successfully 
experimented  on  received  a  sad  illustration  last  winter  in  Vienna. 

Dr.  Hoffman,  a  young  and  promising  ph3'sician,  who  was  making 
some  experimental  investigations  on  animals  with  pure  cultures,  accident- 
ally inoculated  himself  with  the  needle  used  for  making  the  inoculations, 
and  died  from  acute  glanders  in  a  few  days.  Observations  of  veterinar}' 
surgeons  and  experimental  researches  have  shown,  conclusively,  that  the 
disease  can  be  transmitted  from  the  mother  to  the  foetus  m  utero  by 
passage  of  the  bacilli  through  the  placenta  from  the  maternal  into  the 
foetal  circulation.  When  man  is  the  subject  of  glanders,  bacilli  are  found 
more  constantly  in  the  blood  than  in  glanderous  animals.  In  the  case 
described  by  Weichselbaum,  numerous  bacilli  could  be  seen  in  the  blood. 
In  this  case  a  thrombus  was  found  in  one  of  the  large  meningeal  veins, 
containing  numerous  bacilli,  and  which,  undoubtedly,  was  one  of  the 
sources  of  the  bacilli  in  the  circulation.  In  man  the  nasal  mucous  mem- 
brane is  not  so  frequently'  affected  as  in  animals,  although  Bollinger  has 
shown  that  in  hoi-ses  the  nasal  cavity  is  not  always  affected,  and  that  it 
may  present  a  normal  condition,  even  when  the  larynx  and  lungs  are 
seriously  affected.  Muscular  abscesses,  that  may  assimilate  rheumatism, 
are  a  frequent  occurrence,  especially  in  the  chronic  form  of  the  disease. 

SYMPTOMS   AND    DIAGNOSIS. 

The  symptomatology  of  glanders  is  variable,  as  it  is  greatly  modi- 
fied by  the  intensity  of  the  infection,  the  primary  location  of  the  disease. 


SYMPTOMS   AND    DIAGNOSIS.  597 

and  the  number  and  distribution  of  the  metastatic  foci.  The  disease 
may  begin  at  a  single  point,  and  may  then  be  mistaken  for  a  carbuncle 
or  a  gangrenous  erysipelas.  Griefe  reports  a  case  which  began  as  an 
acute  exophthalmos,  and  the  nature  of  the  disease  was  not  ascertained 
until  after  death.  In  this  case  there  were  nodules  in  the  choroid  of  the 
eye.  Acute  glanders  runs  a  rapid  and  malignant  course.  Infection 
usually  takes  place  through  a  small  wound-puncture  or  abrasion  about 
the  face  or  hands.  At  the  point  of  inoculation  a  somewhat  elongated, 
soft,  inflammatory  swelling  or  nodule  forms  in  a  few  days.  Central 
softening  and  suppuration  soon  transform  the  inflammatory  product  into 
an  undermined  ulcer,  with  irregular,  ragged  margins,  surrounded  by  a 
wall  of  infiltration.  In  mild  cases  the  disease  may  remain  local,  and  the 
ulcer  heals  under  proper  treatment  in  a  few  weeks.  In  other  cases 
regional  infection  takes  place,  and  the  l3rnphatic  glands  become  swollen 
and  suppurate,  leaving  the  same  kind  of  ulcers  as  at  the  primary  seat  of 
infection. 

In  the  fatal  cases  general  infection  takes  place  either  through  the 
veins  or  the  lymphatic  vessels,  and  the  symptoms  then  resemble  septi- 
caemia or  pyaemia,  or  a  combination  of  these  two  diseases, — septico- 
P3'semia.  If  infection  take  place  directly  through  the  veins,  a  thrombo- 
phlebitis develops  in  connection  with  one  of  the  nodules  and  the  bacilli 
in  the  thrombus,  which  multipl}'  in  this  nutrient  medium  and  gain  entrance 
into  the  general  circulation  singly  or  through  the  medium  of  infected 
emboli.  Under  such  circumstances,  nodules  are  found  in  the  lungs, 
kidneys,  and  other  internal  organs,  as  suppurating  metastatic  deposits 
in  muscles,  bone,  joints,  and  testicle.  In  such  cases  the  general  symp- 
toms may  simulate  to  perfection  typhoid  fever,  pyaemia,  suppurative 
osteomyelitis,  and  acute  general  miliary  tuberculosis.  In  acute  cases, 
where  general  infection  occurs  earl}^  and  rapidly,  death  results  in  from 
one  to  three  or  four  weeks,  while  in  chronic  cases  the  final  fatal  termi- 
nation is  often  postponed  for  months.  In  illustration  of  the  clinical 
history  of  this  disease  I  will  quote  briefly  a  few  cases. 

A  Russian  medical  journal  of  recent  date  states  that  a  young- 
soldier,  who  had  been  a  wagoner  before  his  admission  into  the  arm3',was 
received  into  the  military  hospital  suffering  from  two  foul  ulcers  on  the 
hard  palate,  which  had  perforated  the  nasal  fossa  and  destroyed  the 
inferior  turbinated  bones.  Three  weeks  later  a  swelling  appeared  over 
the  eyebrow ;  a  fortnight  afterward  he  complained  of  pain  on  the  inner 
side  of  the  left  knee,  around  the  internal  tuberosity  of  the  tibia.  A 
purulent  discharge  occurred  from  the  left  ear,  and,  at  the  same  time,  an 
abscess  developed  on  the  back  of  the  right  hand  which  appeared  as  a 
deep-purple  tubercle,  with  a  hard  circumference,  and  sunken  toward  the 


598 


PRINCIPLES    OF    SURGERY. 


centre  ;  a  purulent  discharge  oozed  from  the  surface.  At  first,  for  a 
sliort  time  after  admission,  the  temperature  varied,  rising  in  the  evening 
to  103°  to  104°  F. ;  later  on  it  fell  to  normal.  The  disease  was  mistaken 
for  syphilis,  and  iodide  of  potassium  was  given  without  the  least  benefit. 
About  ten  weeks  after  admission  he  was  in  better  health,  and  left  the 
hospital,  receiving  his  discharge  from  the  army.  Within  a  few  weeks  he 
returned,  with  extension  of  ulceration  of  the  hard  palate;  the  uvula  was 
destroyed.  The  characteristic  nodules,  the  "  fare}'  buds,"  appeared  in 
the  face ;  the  metastatic  abscess  on  the  back  of  the  hand  remained.  The 
patient  ultimatelj'  died  of  exhaustion.  Before  death  some  of  the  nodules 
were  extirpated  ;  the}'  were  found  to  contain  micro-organisms  reseml)ling 
to  perfection  the  bacillus  of  Loffler  and  Schiitz. 

Kiittner  reports  a  number  of  cases  in  which  the  skin  was  the  seat 

of  numerous  points  of  suppuration 
in  the  form  of  pustules,  or  more 
diffuse  abscesses  followed  by  ulcera- 
tion. The  disease  has  been  mistaken 
more  frequently  for  syphilis  than 
any  other  affection.  This  mistake 
in  diagnosis  is  very  liable  to  be 
made  in  the  chronic  form,  in  which 
the  nodules  grow  ver}'  slowh',  are 
hard,  and  may  occur  in  groups  or 
like  a  string  of  beads.  The  nodules 
usually  soften,  and  form  chronic 
ulcers,  that  closely  resemble  the 
FIG.  109.-ACUTE  Glanders,  involv-  "leers  resulting  from  the  breaking 
^^^  t^^rolf^llV'K^J'Tr^l  ^lown  of  gummata.  If  the  disease 
lo^s:''f^\^^h%l^sckM^^^^^  primarily  attack  the  nasal  cavity, 

the  mucous  membrane  presents 
hard  nodules,  and  a  copious  discharge  from  the  nose  is  present.  In  acute 
glanders  affecting  the  nose  and  face,  extensive  destruction  of  tissue  by 
the  rapid  breaking  down  of  the  nodules  is  one  of  the  prominent  clinical 
features  of  the  disease.  Complete  destruction  of  the  nose,  with  formation 
of  large  ulcers  of  the  face,  may  happen  in  the  course  of  a  week. 

Chronic  glanders  may  also  be  easil}'  mistaken  for  tuberculosis  of 
the  skin,  mucous  membranes,  and  hmphatic  glands.  Acute  glanders  may 
simulate  furuncle,  carbuncle,  and  other  acute  suppurative  lesions,  as  well 
as  l^'mphangitis  and  er3-sipelas.  In  making  a  differential  diagnosis  be- 
tween these  different  affections  and  glanders,  it  is  important,  if  possible, 
to  trace  the  infection  to  its  proper  source.  If  the  clinical  history  point 
to  the  possibilit}^  of  infection  by  contact  with  a  glanderous  horse,  it 


PATHOLOGY    AND    MORBID    ANATOMY.  599 

should  be  remembered  that  the  period  of  incubation  in  man  varies  from 
two  daj'S  to  three  weeks.  A  positive  diagnosis  must  necessaril}^  rest  on 
the  detection  of  the  specific  microbe  in  the  granulation  tissue  or  in  the 
discharges,  and  the  results  obtained  by  inoculation  experiments.  As  soon 
as  general  infection  has  taken  place,  the  symptoms  resemble  pyaemia  or 
septicaemia  ;  so  that  a  differential  diagnosis  between  metastatic  glanders 
and  general  infectiou  with  pus-microbes  cannot  be  made  without  the  aid 
of  the  microscope  and  inoculation  experiments. 

PATHOLOGY   AND    MORBID    ANATOMY. 

The  bacillus  of  glanders  resembles,  in  its  immediate  action  on  the 
tissues,  both  the  bacillus  of  tuberculosis  and  the  pus-microbes.  The 
histological  change  first  observed  in  the  infected  tissues  is  a  transforma- 
tion of  mature  into  embryonal  tissue,  the  microscopical  picture,  with  the 
exception  of  the  absence  of  giant  cells,  resembling  tubercle  ;  but  this  stage 
is  of  short  duration,  as  the  p3'ogenic  effect  of  the  bacillus  of  glanders 
soon  produces  purulent  softening  by  the  speedv  conversion  of  the  embry- 
onal cells  and  leucocytes  into  pus-corpuscles.  The  formation  of  abscesses 
is  a  constant  occurrence,  wherever  localization  has  taken  place,  either  b}' 
direct  infection,  secondar}'  infection  from  regional  diff'usion  through  the 
l^'mphatic  vessels  and  connective-tissue  spaces,  or  b}^  general  infection 
b^'  embolic  diffusion  through  the  general  circulation. 

As  soon  as  the  disease  has  become  general,  the  clinical  picture  and 
pathological  conditions  are  the  same  as  in  pyaemia  caused  bj'  a  suppu- 
rative lesion.  The  differentiation  between  the  two  forms  of  metastasis 
can  be  made  onl}'  by  demonstrating  the  priniar}-  cause,  by  use  of  the 
microscope,  or  b}'  the  results  obtained  from  inoculation  experiments. 
The  pus  found  in  glanders  is  gi'ayish  red  in  color,  and  quite  tenacious  in 
recent  lesions,  but  after  opening  the  abscesses  it  assumes  the  character  of 
ordinary  pus,  as  the  abscess-cavities  then  become  the  seat  of  secondary 
infection  with  pus-microbes.  Swelling  and  abscesses  of  the  testicles  have 
been  frequently  observed  in  cases  where  the  disease  has  become  general, 
the  affection  in  these  organs  l)eing  one  of  the  clinical  manifestations 
that  embolic  dissemination  has  occurred.  Primar}'  glanders  of  the  lungs 
from  inhalation  of  the  microbes  into  the  air-passages  gives  rise  to  symp- 
toms and  pathological  conditions  that  cannot  be  distinguished  from  pul- 
monary tuberculosis,  unless  the  essential  cause  can  be  demonstrated  in 
the  sputa  under  the  microscope,  or  glanders  can  be  artificiallj-  produced 
by  the  injection  of  sputum  into  the  subcutaneous  tissue  or  the  peritoneal 
cavit}'  of  guinea-pigs.  The  pulmonar}'^  nodules  soften  and  suppurate, 
and  cavities  form  in  the  same  manner  as  in  pulmonarj-  tuberculosis. 


600  PRINCIPLES   OF    SURGERY. 

PROGNOSIS. 

The  prognosis  in  glanders  should  alwa3^s  be  guarded,  as  a  limited 
local  lesion  may  be  followed  by  a  fatal  form  of  general  infection.  The 
prognosis  is  comparatively  favorable  if  the  infection  remain  limited  to 
a  circumscribed  area  accessible  to  direct  surgical  treatment.  It  must  be 
more  guarded  if  regional  infection  through  the  lymphatic  vessels  has 
occurred,  and  it  is  absolutely  fatal  in  cases  of  primary  glanders  of  im- 
portant internal  organs,  and  when  general  infection  has  followed  in  the 
course  of  a  local  lesion  with  or  without  regional  dissemination.  In  the 
local  form  of  the  disease  the  ulcerations  usually  prove  inveterate  to 
treatment,  and  final  recovery  is  often  retarded  for  months  by  extensive 
undermining  of  the  sliin.  Acute  glanders  with  general  infection,  as  a 
rule,  proves  fatal  within  one  to  three  weeks,  and  death  occurs  in  conse- 
quence of  septic  infection. 

TREATMENT. 

The  prophylactic  treatment  consists  in  preventing  infection  from 
glanderous  horses  and  substances  which  have  become  contaminated  with 
the  specific  virus  from  diseased  animals,  and  requires  earl}^  recognition 
of  the  disease  and  killing  of  the  affected  animals,  as  well  as  thorough 
disinfection  of  tlie  premises  occupied  b}'  the  diseased  beast.  The  ca- 
davers should  be  cremated  or  deeply  buried.  Abrasions  or  granulating 
surfaces  that  have  been  exposed  to  infection  should  be  cauterized. 

In  cases -of  primar}^  pulmonar}'^  or  intestinal  glanders,  and  after 
general  infection  from  a  local  form  of  the  disease  has  occurred,  the 
treatment  must  be  necessarily  symptomatic,  as  such  cases  are  be3'0nd 
the  reach  of  local  or  general  treatment.  The  embarrassed  respiration 
and  feeble  and  rapid  pulse  indicate  the  use  of  alcoholic  stimulants.  A 
primary  nodule  should  be  removed  by  excision,  taking  all  necessary  pre- 
cautions to  prevent  infection  of  the  wound  in  case  the  skin  has  been 
destroyed  by  ulceration.  Limited  regional  infection  should  be  treated 
in  the  same  manner  if  ulceration  has  not  taken  place,  and  the  conditions 
are  such  that  all  of  the  infected  tissues  can  be  removed  with  safety. 

After  multiple  abscesses  have  formed  a  radical  operation  is  no 
longer  indicated,  the  extent  of  the  affection  precluding  the  possibility 
of  removing  all  of  the  infected  tissues.  In  such  cases  the  abscesses 
should  be  freel}-  incised,  fistulous  tracts  laid  open,  undermined  skin  cut 
away,  and,  as  far  as  possible,  the  infected  tissues  removed  with  a  sharp 
spoon;  then  the  entire  surface  should  be  disinfected  with  a  12-per-cent. 
solution  of  chloride  of  zinc.  No  attempt  should  be  made,  under  such 
circumstances,  to  obtain  healing  of  the  superficial  wounds  until  it  be- 
comes apparent  tliat  the  specific  microbic  cause  has  been  eliminated  or 


TREATMENT.  601 

destroyed,  and  several  repetitions  of  the  curetting  and  disinfection  may 
become  necessjuy  until  this  object  is  realized.  The  scraped  surfaces 
should  be  kept  covered  with  a  moist  antiseptic  compress  gauze,  wrung 
out  of  l-to-2000  solution  of  corrosive  sublimate  or  a  2-per-cent.  solution 
of  carbolic  acid.  If  the  i)rolonged  use  of  these  antiseptics  is  objection- 
able, on  account  of  danger  from  absorption  of  toxic  doses  of  drugs,  strong 
iodine-water  can  be  used  in  the  same  wa}'.  The  internal  use  of  iodine, 
creasote,  and  arsenic  have  been  recommended  as  specifics  in  the  treat- 
ment of  glanders,  but  clinical  experience  has  not  supported  this  claim, 
and  the  surgeon  must  rely  upon  local  measures  in  his  efforts  to  pro- 
tect the  patient  against  tlie  dangers  arising  from  regional  and  general 
infection  ;  while  he  must  aim,  at  the  same  time,  to  maintain  the  resisting 
power  of  the  tissues  to  the  microbic  invasion  by  a  supporting  tonic  and 
stimulating  treatment- 


INDEX. 


Abnormal  and  defective  callus,  53 
Abscess,  212 
acute,  214 
diagnosis,  215 
treatment,  217 
chronic,  219 
diagnosis,  219 
treatment,  220 
of  brain,  271 
cerebral  localization,  273-277 
prognosis,  272 

symptoms  and  diagnosis,  272 
treatment,  273 
of  internal  organs,  259 
of  lung,  diagnosis,  287 
exploration,  288 
operation,  288 
tubercular,  450 
pathological  anatomy,  450,  451 
prognosis,  453 

symptoms  and  diagnosis,  452 
treatment,  453-457 
Absolute  asepsis,  23 
Accurate  suturing,  25 
Achromatine,  8 
Actinomycosis  hominis,  549 
clinical  varieties,  555-562 
description  of  fungus,  550-552 
history,  549 
of  brain,  564 

of  bronchial  tubes  and  lungs,  562 
pathology   and   morbid    anatomy, 

553,  554 
prognosis,  567 
sources  of  infection,  553 
symptoms  and  diagnosis,  565,  566 
treatment,  568 
Action  of  bacteria  on  tissues  of  body, 

134 
Acute  suppuration,  209 
tetanus,  397 


Amputation  in  tuberculosis  of  joints, 

524 
Anthrax,  571 

attenviation  of  virus,  577 

clinical  varieties,  578 

description  of  bacillus,  572 

diflferential  diagnosis,  584 

history,  571 

in  living  body  and  in  soil,  573 

infection  in  man,  576 

inoculation  experiments,  574,  575 

intensification  of  virus,  576 

multiplication,  573 

oedema,  580 

of  external  surface,  579 

pathology  and  morbid  anatomy,  581 

prognosis,  585 

prophylactic  inoculations,  577 

pustule,  580 

treatment,  585-588 
Antiphlogistic  treatment  of  inflamma- 
tion, 120 
Arterial  blood-supply,  defective,  165 
Arteries,  ligation  of,  165 
Arthrectomy  in  tuberculosis  of  joints, 

518,  519 
Arthritis,  suppurative,  259 
Ascites,  482 

Aspiration  in  tuberculosis  of  joints,  517 
Attenuation  of  pathogenic  bacteria,  136 
Atypical  resection,  520-522 

Bacilli  of  putrefaction,  315-322 
Bacillus  of  anthrax,  description  of,  572 
multiplication  of,  573 
mallei,  589 
description  of,  590 
tenacity  of,  591 
pyocyaneus,  204 
pyogenes  fcetidus,  204 
saprogenes,  315   316 

(603) 


604 


INDEX. 


Bacillus  tetani,  384 

ptomaines  of,  390,  391 
tuberculosis,  423 
cultivation,  426 
description,  423 

manner  of  infection  and  dissemi- 
nation, 4G9,  470 
stainins,  424,  425 
Bacteria,  127 

action  of,  on  tissues  of  body,  134 

attenuation,  136 

classification,  127 

cultivation,  131-133 

elimination,  149,  150 

fission,  129 

growth,  134 

inoculation  experiments,  135 

localization,  141-146 

multiplication,  129 

outside  of  the  body,  138 

presence  of,  in  healthy  body,  139 

140 
putrefactive,  163 
secondary  or  mixed  infection,  146- 

149 
specific,  160-162 
spores,  130 

therapeutic  inoculation,  137 
transmission   of,    from    parents   to 
foetus,  151-155 
Bacteridia,  571 

Bacteriological  causes  of  suppuration, 
191 
researches,  232,  233,  259,  260,  280, 
281,  291-298,  303-311,  334-337, 
383-391,  461,  462,  491,  492 
Bladder,  tuberculosis  of,  544 
prognosis  and  treatment,  545 
symptoms  and  diagnosis,  545 
Blood-corpuscles,  red,  71 

white,  70 
Blood-plates,  72 
Blood-vessels,  42 
Bone,  49 

tuberculosis  of,  489 
artificial,  490 

clinical   and    bacteriological   re- 
searches, 491,  492 
means  of  differential  diagnosis, 
500,  501 


Bone,   tuberculosis  of,    pathology   and 
morbid  anatomy,  493-496 
prognosis,  502 

symptoms  and  diagnosis,  497-500 
treatment,  503-507 
Brain-abscess,  271-280 
Brain,  actinomycosis  of,  564 
exploration  of,  278-280 
Bronchial  tubes  and  lungs,  actinomy- 
cosis of,  562 

Callus,  53 

Capillary  vessels,  68,  69 
Cancer  aquations,  180 
Carbuncle,  229 

diagnosis,  230 

treatment,  230 
Cartilage,  34,  107 
Catarrhal  inflammation,  101 
Caustics  producing  necrosis,  167 
Cauterization  of  wounds,  418 
Cavum  Retzii,  215 
Cell  division,  13 
Central  nervous  system,  57 
Chemical  pyogenic  substances,  194 
Chromatin,  8 

Chronic  circumscribed  suppurative  os- 
teomyelitis, 256 
pathological  anatomy,  257 
symptoms,  257 
treatment,  257,  258 

inflammation,  111-114 

suppuration,  210 

tetanus,  398 
Cicatrization,  19 
Classification  of  bacteria,  127 
Clinical  forms  of  septicaemia,  312-331 

surgical  tuberculosis,  447 
Coagulation  necrosis,  175,  176 
Cold  producing  necrosis,  167 
Color  in  gangrene,  171 
Condition  of  tissues  in  necrosis,  171 
Connective  tissue,  41 
Cornea,  31,  103-107 
Corpuscle,  third,  72 
Croupous  inflammation,  102,  103 
Cultivation  of  bacteria,  131,  133 

Decubitus,  164,  180 

Defective  arterial  blood-supply,  166 


INDEX. 


605 


Diabetic  gangrene,  179 

Diapedesis,  87 

Direct  causes  of  suppuration,  194-205 

transmission  of  bacteria,  151 
Disturbance  of  function,  91 
Division  of  cells,  13 
Dry  gangrene,  178 

Elimination  of  gangrenous  part,  173 

pathogenic  bacteria,  149,  150 
Embolism,  343-348 
Emigration  of  leucocytes,  83-87 
Emphysema,  171 
Empyema,  280 

after-treatment,  285 
multiple  resection,  286 
thoracoplastic  operation,  286 
bacteriological  studies,  280,  281 
diagnosis,  282 
prognosis,  282 
treatment,  283 
drainage,  285 
evacuation  of  pus  and  removal  of 

membranes,  284 
incisions,  283 
irrigation,  285 
resection  of  rib,  284 
Encapsulation  of  necrosed  tissue,  173 
Endocranial  suppuration,  263-271 
Epidermization,  22 

Epididymis   and    testicle,   tuberculosis 
of,  541 
symptoms  and  diagnosis,  542 
treatment,  543 
Epiphyseolysis,  239 
Epithelia,  36 
Epithelioid  cells,  439 
Ergot  the  cause  of  gangrene,  167 
Ergotine,  184 
Erysipelas,  359 
bullosum,  373 
clinical  forms,  373-376 
cultivation,  361 
description  of  streptococcus  erysipe- 

latosus,  361 
erythematosum,  373 
facialis,  376 
gangrsenosum,  374 
history  of  microbic  origin,  359,  860 
inoculation  experiments,  362 


Erysipelas,     inoculation    experiments, 
for  therapeutic  purposes,  362 
manner  of  infection,  364-366 
metastaticum,  375 
migrans,  375 
prognosis,  377 

relation  of,  to  puerperal  fever,  3G7 
to     phlegmonous     inflammation 
and  suppuration,  368,  369 
symptoms  and  diagnosis,  370-372 
traumatic,  376 
treatment,  377-379 
Erysipeloid,  380,  381 
Essential  condition  for  growth  of  bac- 
teria, 134 
Excision  of  wounds,  413 
Experiments,  inoculation,  of  bacteria, 

135 
Exploration  of  brain,  378-280 

of  lung,  288 
External  parts,  gangrene  of,  168 
Exudation,  inflammatory,  83 

Fallopian  tubes,  tuberculosis  of,  538 

symptoms  and  diagnosis,  539 

treatment,  540 
Farcy,  acute,  595 

chronic,  595 
Fascia  tuberculosis,  530 
Fermentation  fever,  313 

symptoms  and  diagnosis,  314 
Fibrous  tubercle,  443 
Fission  of  bacteria,  129 
Five  phases  of  chromatin  substance,  9 
Fixed  tissue-cells,  73 
Foot,  perforating  ulcer  of,  183 
Fragmentation  of  nucleus,  12 
Function,  disturbance  of,  91 
Furuncle,  227 

Gangrene,  caused  by  ergot,  167 
color  in,  171 
diabetic,  179 
dry,  178 

hospital,  181,  182 
line  of  demarcation,  172 
moist,  178 

of  external  parts,  168 
prognosis,  184 
progressive,  177,  178 


606 


INDEX. 


Gangrene,  senile,  179 

SAvelling,  171 

treatment,  185-189 
Genito-urinary  organs,  tuberculosis  of, 

537 
Giant  cells,  437-439 
Glanders,  589 

acute,  594 

bacteriological  history  of,  589 

chronic,  595 

in  the  horse,  594 

in  man,  596 

inoculation  experiments,  591-594 

pathology   and    morbid    anatomy, 
599 

prognosis,  600 

symptoms  and  diagnosis,  596-598 

treatment,  600,  601 
Glands,  56 
Glans   penis  and  urethra,  tuberculosis 

of,  541 
Granulating  surfaces,  skin-grafting  in, 

38 
Granulation  tissue,  13 

vascularization  of,  16 
Granulomata,  112 
Growth  of  bacteria,  134 

HEMORRHAGIC   INFLAMMATION,  95 

Haemostasis,  24 

Head  tetanus,  398 

Healing  of  wounds,  3 

Heat  producing  necrosis,  166 

Histogenesis  of  suppuration,  191 

of  tubercle,  435,  436 
Histological  structure  of  tubercle,  437- 

442 
Histology  of  tubercle,  433,  434 
Histozym,  313 
Hospital  gangrene,  181,  182 
Hyaline  tubercle,  444 
Hydrophobia,  403 

a  microbic  disease,  405,  406 

causes,  407 

in  the  dog,  404 

pathology  and    morbid    anatomy, 
411,  412 

prognosis,  410 

sj^mptoms  and  diagnosis,  407-409 

treatment,  413 


Hydrophobia,  treatment,  cauterization 
of  wound,  413 
excision  of  wound,  413 
palliative,  416,  417 
prophylactic,  413,  414 

Icterus,  hfematogenous,  349 
Immediate  or  direct  union  of  wounds,  3 
Incubation  period  of  tetanus,  392 
Indirect  causes  of  suppuration,  193 
Infection-atrium  of  bacillus  tetani,  393, 

394 
Inflammation,  67,  158,  159 
chronic.  111,  114 
hfemorrhagic,  95 
histological  elements  in,  68 
interstitial,  95 
modification  of,  93 
of  mucous  membranes,  101,  102 
of  non -vascular  tissue,  103 
of  serous  membranes,  96-100 
parenchjmiatous,  93 
prognosis,  116 
suppurative,  96 
symptoms,  74-91 
symptoms  and  diagnosis,  114-116 
treatment,  117 
anodynes,  125 
antiphlogistic,  120 
antipyretics,  123 
antiseptic  fomentations,  122 
application  of  cold,  122 
counter-irritation,  126 
diet,  124 

elevation  of  part,  121 
ignipuncture,  126 
massage,  125 
parenchymatous  injections,  118, 

119 
physiological  rest,  121 
stimulants,  124 
tonics  and  alteratives,  125 
Inflammatory  exudation,  83 

transudation, 90 
Inoculation  experiments  of  bacteria,  135 

of  tuberculosis,  426-428 
Inoculation-tuberculosis   in  man,  429- 

433 
Inoculations,  prophylactic.  414-416 
Internal  ear,  tuberculosis  of  457 


INDEX. 


60' 


Internal  ear,  necrosis,  168 
organs,  abscess  of,  259 
Iris,  tuberculosis  of,  458 

Joints,  tuberculosis  of,  507 
etiology,  507 

pathology  and  morbid  anatomy,  508 
prognosis,  514 

symptoms  and  diagnosis,  511-514 
treatment,  515 

amputation,  524 

arthrectomy,  518,  519 

aspiration,  517 

atypical  resection,  520-522 

rest,  516 

subcutaneous  evacuation,  517 

typical  resection,  523 
varieties  of,  509-511 

Karyokinesis,  8 
Karyolysis,  168 
Karyomitosis,  8 
Karyorbexis,  168,  17'; 

Large  cavities,  suppuration  in,  259 
Leptomeningitis,  suppurative,  267,  268 
Leucocyte,  70,  437 

emigration  of,  83-87 
Ligation  of  arteries  in  tbeir  continuity, 

165 
Liquefaction  of  necrosed  tissue,  173 
Localization  of  bacteria,  141-146 
Loss  of  function  in  osteomyelitis,  239 
Lung-abscess,  287-289 
Lupus,  tubercular  nature  of,  459-462 
Lymphatic  glands,  tuberculosis  of,  469 

pathological  histology  and  morbid 
anatomy,  471 

prognosis,  475 

symptoms  and  diagnosis,  472-474 

treatment,  476-480 
Lyssa  nervosa  falsa,  410 

Macrocytes,  438 
Malignant  oedema,  309-311 
Mammary  gland,  tuberculosis  of,  536 
Metastatic  suppuratiqn,  349-351 
Microbe  enchapelet,  334 
Microbic  cause  of  tetanus,  392 
origin  of  erysipelas,  359,  360 


Microbic  origin  of  suppuration,  191, 192 

of  tuberculosis,  419-422 
Micrococcus  pyogenes  tenuis,  202 
Modification  of  inflammation,  93 
Moist  gangrene,  178 
Mouth  and  tongue,  tuberculosis  of,  533 

pathology,  532 

symptoms  and  diagnosis,  533 

treatment,  534 
Mucous   membrane,    inflammation    of 
101,  103 

of  intestines,  tuberculosis  of,  535 

suppurative  inflammation  of,  212 

transplantation  of,  41 
Mummification,  172 
Muscles,  46 

non-striated  muscular  fibre,  46 

striated  muscular  fibre,  46 

suture  of,  49 
Myeloplaques,  438 

Necrobiosis,  177 

Necrosed  tissue,  liquefaction  of,  173 

Necrosis,  157 

coagulation,  175,  176 

etiology,  158-167 

general  symptoms,  174 

internal,  168 

pathological  and  clinical  varieties, 
175-189 

prognosis,  184 

symptoms,  168-174 

treatment,  185-189 
Nerve  suture,  62 

primary,  63 

secondary,  63 
Nerves,  peripheral,  58 
Nervous  system,  central,  57 
Noma,  180 

Non-vascular  tissue,  31 
cartilage,  34 
cornea,  31 

infiammation  of,  103 
Nucleus,  fragmentation  of,  13 

Obstructed  venous  circulation,  166 
Odor  of  necrosed  tissue,  172 
(Edema,  malignant,  309-311 
Opening  of  the  skull,  278 
Operation,  thoracopiastic,  288 


608 


INDEX. 


Origin  of  suppuration,  191,  193 
Osseous  tuberculosis,  cause  of,  489 
Osteomyelitis,  suppurative,  231 

early  operations,  248 

intermediate  operations,  249,  250 

late  operations,  251-256 

Pachymeningitis,  suppurative,  263 
Pain  a  symptom  of  necrosis,  169 

of  osteomyelitis,  237 
Parenchymatous  inflammation,  93 
Paronychia,   226 
Pathogenic  bacteria,  127 

attenuation,  136 

classification,  127 

cultivation,  131-133 

elimination,  149,  150 

inoculation,  137 

localization,  141-146 

multiplication,  129 

presence  of,  in  healthy  body,  139, 
140 

secondary  or  mixed  infection,  146- 
149 

transmission   of,    from    parents   to 
foetus,  151-155 
Perforating  ulcer  of  foot,  183 

of  stomach  and  duodenum,  188 
Pericarditis,  suppurative,  289 
Pericardium,  incision  and  drainage,  290 

puncture  and  aspiration,  290 
Peripheral  nerves,  58 
Peritoneum,  tuberculosis  of,  480 

bacteriological  remarks,  480 

clinical  studies,  481 

pathology  and  morbid  anatomy, 482 

symptoms  and  diagnosis,  483 

treatment,  484-487 
Peritonitis,  adhesive,  483 

fibrino-plastic,  483 

plastic  and  suppurative,  295 

suppurative,  291-302 
Phagocytosis,  108-111 
Phlegmonous  inflammation,  relation  of 
erysipelas  to,  368 

with  suppuration,  220 
Physiological  rest,  26 
Plasma  rhexis,  177 
Progressive  gangrene,  177 

with  emphysema,  178 


Prophylactic  inoculations,  414-416 
Proteus  mirabilis,  317 
vulgaris,  316 
Zenkeri,  317 
Ptomaines,  134,  198-200,  317-322 
of  bacillus  tetani,  390,  391 
of  pus-microbes  as  a  cause  of  sup- 
puration, 198-200 
Puerperal  fever,  relation  of  erysipelas 

to,  367 
Pulse,  after  ligation  of  artery,  170 
Purulent  infiltration,  progressive,  223 
Pus,  205 

corpuscles,  206-208 
microbes,  195-198 
description  and  specific  action  of, 

200-205 
ptomaines  of,  198-200 
serum,  206 
Putrefactive  bacteria,  163 
Pyaemia,  333 

bacteriological    and    experimental 

researches,  334^337 
etiology,  338-347 
in  rabbits,  335 

pathological  anatomy,  353,  353 
prognosis,  352 

symptoms  and  diagnosis,  348-351 
treatment,  354-356 
Pyogenic  microbes  as  a  cause  of  sepsis, 
311 
substances,  chemical,  194 

Redness  a  symptom  of  osteomyelitis, 

238 
Regeneration,  1 

of  different  tissues,  31 
Reticulum,  tubercle,  440 
Rib,  resection  of,  284 
Ribs,  multiple  resection  of,  286 

Sapr^mia,  315 

prognosis,  323 

symptoms  and  diagnosis,  322 

treatment,  333,  324 
Senile  gangrene,  179 
Sepsis,  pyogenic  microbes  as  a  cause  of, 

311 
Septicaemia,  303 

bacteriological  researches,  303-311 


INDEX. 


609 


Septicaemia,  clinical  forms  of,  312-331 

in  mice,  304,  305 

in  rabbits,  306^300 

progressive,  325 
causes,  325,  326 
pathology  and  morbid  anatomy, 

330 
prognosis,  329 

symptoms  and  diagnosis,  327,  328 
treatment,  330,  331 
Septicopysemia,  356-358 

kryptogenetic,  357 

spontaneous,  357 
Serous   membranes,    inflammation   of, 

96-100 
Skin-grafting,  38,  39 
Skin,  tuberculosis  of,  459 

pathology  and  morbid  anatomy,  462 

prognosis,  466 

symptoms  and  diagnosis,  463-465 

treatment,  466-468 
Skull,  opening  of,  278 
Specific  bacteria,  160-162 
Spores  of  bacteria,  130 
Staphylococcus  cereus  albus,  202 

cereus  flavus,  202 

flavescens,  202 

pyogenes  albus,  201 

pyogenes  aureus,  201 

pyogenes  citreus,  201 
Stomach    and    duodenum,    perforating 

ulcer  of,  183 
Streptococcus  erysipelatosus,  361 

pyogenes,  203 
Subacute  suppuration,  210 
Suppuration,  191 

acute,  207 

bacterial  causes  and  histogenesis  of, 
191 

chronic,  210 

clinical  forms,  209 

direct  causes,  194-205 

endocranial,  263-271 

history  of  microbic  origin,  191,  192 

in  large  cavities,  259 

in  wounds,  211 

indirect  causes,  193 

pus,  205-208 

relation  of  erysipelas  to,  368,  369 

subacute,  210 


Suppurative  arthritis,  259 

bacteriological  researches,  259, 260 
symptoms  and  diagnosis,  261 
treatment,  261-263 
inflammation,  96,  101 

of  mucous  membrane,  213-230 
leptomeningitis,  267,  268 

symptoms  and  diagnosis,  269 
treatment,  270 
osteomyelitis,  231 
bacteriological  and  experimental 

investigations,  232,  233 
causes,  234,  235 

chronic  circumscribed,  256-258 
diagnosis,  239,  240 
history,  231 

pathological  anatom}%  242,  243 
prognosis,  241 
symptoms,  236-238 
treatment,  244-255 
pachj'uieningitis,  263 
symptoms  and  diagnosis,  264 
treatment,  265-267 
pericarditis,  289 
peritonitis,  291 
bacteriological  and  experimental 

researches,  291-298 
causes,  295-297 

clinical  and  bacteriological  stud- 
ies, 294 
symptoms  and  diagnosis,  298,  299 
treatment,  300-302 
tendo-vaginitis,  224 
Surgical  tuberculosis,  419-446 

clinical  forms,  447-468 
Suture  of  muscles,  49 

of  nei'ves,  62-66 
Suturing,  25 

of  granulating  wounds,  29 
Symptoms  of  inflammation,  74-91,  114- 

116 
Synovitis,  238 

Swelling  a  symptom  of  osteomyelitis, 
237 
in  moist  gangrene,  170 

Temperature  in  gangrene,  170 
Tenderness  a  symptom  of  osteomyelitis, 
237 
in  diagnosis  of  necrosis,  169 


39 


(ilO 


INDEX. 


Tetanus,  383 

acute,  397 

bacteriological  studies.  i38-]-891 

clinical  forms,  397,  398 

cultivation,  384 

etiology,  392-394 

liydrophobicus.  398 

infection-atrium,  393,  394 

inoculation  experiments.  385-390 

neonatorum,  398 

pathology   and    morbid    anatomy, 
399^ 

period  of  incubation.  392 

prognosis,  398 

specific  microbic  cause,  392 

symptoms  and  diagnosis,  395-397 

treatment,  399-401 
Therapeutic  inoculation  of  bacteria,  137 
Third  corpuscle,  72 
Thoracoplastic  operation,  286 
Thrombosis,  340-342 
Tissue-cells,  73 
Tissue,  condition  of,  171 

connective,  41 

non-vascular,  31 

vascular,  35 
Tissues,  action  of  bacteria  on,  134 
Transmission  of  bacteria,  151-155 
Transplantation  of  mucous  membrane, 
41 

of  skin,  38 
Transudation,  inflammatory,  90 
Trauma,  163 

Traumatic  erysipelas,  376 
Treatment  of  acute  abscess,  217,  218 

anthrax,  585-588 

brain-abscess,  273 

carbuncle,  230 

chronic  abscess,  220 

empyema,  283-287 

erysipelas,  377-379 

furuncle,  228 

gangrene,  185-189 

glanders,  600,  601 

hydrophobia,  413-417 

inflammation,  117-126 

necrosis,  185-189 

paronychia,  226 

phlegmonous  inflammation,  221,222 

purulent  inflammation.  223 


Treatment  of  pytemia,  354-3.")6 
saprsmia,  323.  324 
septicaemia,  330,  331 
suppurating  wounds,  28 
suppurative  arthritis,  261-263 

leptomeningitis,  270 

osteomyelitis,  244-255 

pachymeningitis.  265-267 

peritonitis,  300-302 

tendo-vaginitis,  225 
tetanus,  399-401 
tubercular  abscess,  453-457 

tendo-vagiuitis,  528-530 
tuberculosis  of  actinomycosis  hom- 
inis,  568 

bladder,  545-548 

bone,  503-507 

epididymis  and  testicle,  543 

Fallopian  tubes,  540 

joints,  515-524 

lymphatic  glands,  476-480 

mammary  gland,  536 

mouth  and  tongue,  584 

peritoneum,  484-487 

skin,  466-468 

vulva,  vagina,  and  uterus,  537 
wounds,  23 

skin-grafting  in.  39 
Trismus,  398 
Tubercle,  fibrous,  443 
hyaline,  444 

nodule,    arrangement   of  cells   in, 
440,  441 

growth  of,  443 
reticulated,  443 
Tubercular  abscess,  450 
ascites,  482 
tendo-vaginitis,  525 

pathology,  525 

prognosis,  527 

symptoms  and  diagnosis,  527 

treatment,  528-530 
Tuberculosis,  surgical,  419 
calcification,  446 
caseation,  444,  445 
description  of  bacillus,  423 
growth  of  tubercle-nodules.  442 
hereditary   and    acquired    disposi- 
tion, 448,  449 
histogenesis  of  tubercle.  435.  436 


INDEX. 


611 


Tubercnlosip,       surgical,       histological 
structure  of  tubercle,  487-441 

histology  of  tubercle,  433,  434 

history  of  microbic  origin,  419-422 

inoculation  experiments,  426-428 
tuberculosis  in  man,  429-432 

pathological  varieties,  443 
Tuberculosis  of  bladder,  544 

bones,  489-507 

epididymis  and  testicle,  541 

Fallopian  tubes,  538 

fascia,  530 

genito-urinary  organs,  537 

glans  penis  and  urethra,  541 

internal  ear,  457 

joints,  507-524 

lymphatic  glands,  409-480 

mammary  gland,  536 

mouth  and  tongue,  532 

mucous  membrane  of  intestines.  535 

peritoneum,  480-487 

the  iris,  458 

the  skin,  459-468 

vesiculse  seminalis,  543 

vulva,  vagina,  and  uterus,  537 
treatment,  538 

Ulcer  of  foot,  183 

of  stomach  and  duodenum,  183 


Union    of  wouuds    by    primary   inten- 
tion, 6 
by  secondary  intention,  27 


Vacuolak  degeneration,  177 
Varieties  of  necrosis,  175-189 

of  tuberculosis  of  joints,  509-511 
Vascular  tissue,  35 

surface  epithelia,  36 
Vascularization  of  granulation  tissue,  16 
Venous  circulation,  obstructed,  166 
VesiculfE  seminalis,  tuberculosis  of,  543 
Vessels,  capillary,  68,  69 
Vulva,  vagina,  and  uterus,  tuberculosis 
of,  537 

Wounds,  cauterization  of,  413 
excision  of,  413 
healing  of,  2 

immediate  or  direct  union,  3 
of  blood-vessels,  42 
skin-grafting  in,  39 
suppuration  in.  211 
suturing  of  granulating,  29 
treatment  of,  23 

absolute  asepsis  in,  23,  28 

of  suppurating,  28 
union  by  primary  intention.  6 

by  secondarv  intention,  27 


MARCH,    1890. 


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This  excellent  manual  comprises  in  its  366  small 
ooiavo  pages  about  as  much  sound  and  valuable  in- 
forniatiori  on  the  subjects  indicated  in  its  title  as 
could  well  be  crowded  into  the  compass.  The  book 
is  exhaustively  and  correctly  indexed,  and  of  a  con- 
venient form.  The  paper,  press-work,  and  binding 
are  excellent,  and  the  typography  (long  primer  and 
brevier)  is  highly  to  be  commended,  as  opposed  to 
the  nonpareil  and  agate  usually  used  incompendsof 
this  sort,  and  which  are  destructive  to  vision  and 
temper  alike. — St.  Louis  Med.  and  Surg.  your. 

In  going  through  it,  we  have  been  favorably  im- 
pres.sed  by  the  plain  and  practical  suggestions  in 
regard  to  prescription  writing,  and  the  metric  sys- 
tem, and  the  other  things  which  must  be  known  in 
order  to  write  good  and  accurate  prescriptions. — 
Medical  and  Surgical  Reporter. 

.Many  works  claim  more  in  their  title-pages  than 
•■an    be   verified    further    on,    but   the   only   adverse 


criticism  we  can  make  on  this  volume  is  that  it  does 
not  claim  enough. — Southern  California  Prac- 
titioner. 

The  book  is  one  of  the  very  best  of  its  class. — 
Columbus  Medical  Journal . 

This  is  a  very  condensed  and  valuable  resume 
of  the  drugs  recognized  by  the  United  States  Phar- 
macopoeia, and  all  the  officinal  and  important 
preparations. — Southern  Medical  Record. 

Dr.  Bowen's  work  is  a  very  valuable  one  indeed, 
and  will  be  found  "  to  fill  a  want  "  beyond  a  doubt. 
—Cincinnati  Medical  News. 

It  is  short  and  concise  in  its  treatment  of  the 
subjects,  yet  it  gives  sufficient  to  gain  a  very  correct 
knowledge  of  everything  that  comes  under  this  head- 
ing. This  is  a  ready  work  for  the  country  physician, 
who  must  of  necessity  have  a  more  practical  acquain- 
tance with  pharmaceutical  processes. — Medical 
Brief. 


Une    I'itno   volanie  of   370  pages.         Handsomely   Bound    in    Dark-Blae   Clotb. 

Price,   poet-paid,  in  the  United    States  and    Canada,  $1.40,   net; 

in  Great  Britain,  6s.  6d.;  in  France,  9  fr.  35. 


(F.  A.  DAVIS.  Medical  Publisher,  Philadelphia.  Pa..  U.S.A.) 


Bashore's  Improved  Clinical  Chart. 


For  the  SEPARATE  PLOTTINa  of  TEMPERATURE,  PULSE,  and  RESPIRATION. 

?  Convenient,   Accurate,   and  Permanent  Daily   Recor 
Hospital  and  Private  Practice. 

By  HARYHY  B.   BASHORK,   m.D. 


Designed  for  the  Convenient,   Accurate,   and  Permanent  Daily   Recording  of  Cases  in 
Hospital  and  Private  Practice. 


CO?TEIGHTED,   1888,   BY  F.  A.  DAVIS. 

SO  Olxarts,  ian  TaTolet  I^orm..  Size,  S2cl2  incites. 


Price,  in  the  United  States  and  Canada,  Post-paid,  50  Cents, 
Net;  Great  Britain,  2s.  6d. ;  France.  3  fr.  60. 

The  above  diagram  is  a  little  more  than  one-fifth  (1-5)  the  actual  size  of  the  chart  and  shows  the 
method  of  plotting,  the  upper  curve  being  the  Temperature,  the  middle  the  Pulse,  and  the  lower  the 
Respiration.     By  this  method  a  full  record  of  each  can  easily  be  kept  with  but  one  color  ink 

It  is  so  arranged  that  all  practitioners  will  find  it  an  invaluable  aid  in  the  treatment  of  their  patients. 

On  the  back  of  e.ich  chart  will  be  found  ample  space  conveniently  arranged  for  recording  "Clinical 
History  and  Symptoms"  and  "Treatment." 

By  its  use  the  physician  will  secure  such  a  complete  record  of  his  cases  as  will  enable  him  to  review 
them  at  any  time.  Thus  he  will  always  have  at  hand  a  source  of  individual  improveuient  and  benefit  in 
the  practice  of  his  profession,  the  value  of  which  can  hardly  be  overestimated. 


(F.  A.  DAVIS.  Medical  Publisher,  Philadelphia.  Pa.,  U.S.A.) 


-4HB  OO^^H^ 


ON 


The  Physician  Himself 


AND  THINGS  THAT  CONCERN 


HIS  REPUTATION  AND  SUCCESS. 


D.    W.    CATHELL,    M.D., 


BALTIMORE,  MD. 


Being    the    NINTH   EDITION   (Enlarged  and    Thoroughly   Revised)    of  the    "PHYSICIAN 

HIMSELF.  AND  WHAT  HE  SHOULD  ADD  TO  HIS  SCIENTIFIC  ACQUIREMENTS 

IN  ORDER  TO  SECURE  SUCCESS.' 


In  One  Handsome  Octavo  Volume  of  298  Pages,  Bound  in  Estra  ClotL 

Priee,  Pc»t-paid,  in  United  States  and  Canada,  $2.00,  Net;  Great 

Britain,  8s.  6d. ;  France,  12  fr.  40. 


This  remarkable  book  has  passed  through  eight  (8)  editions  in  less 
ihun  Hve  years,  has  met  with  the  unanimous  and  hearty  approval  of  the 
Profession,  and  is  practicall}^  indispensable  to  every  young  graduate 
who  aims  at  success  in  his  chosen  profession.  It  has  just  undergone  a 
t  horougli  revision  by  the  author,  who  has  added  much  new  matter  cover- 
ing many  points  and  elucidating  many  excellent  ideas  not  included  in 
former  editions.  This  unique  book,  the  onl}^  complete  one  of  the  kind 
ever  written,  will  prove  of  inestimable  pleasure  and  value  to  the  practi- 
tioner of  many  years'  standing,  as  well  as  to  the  young  physician  who 
needs  just  such  a  work  to  point  the  way  to  success. 

We  give  below  a  few  of  ^le  many  unsolicited  letters  received  by 
the  author,  and  exti'acts  from  reviews  in  the  Medical  Jciurnals  of  tlie 
fonniM'  editions : 


"  '  The  Physician  Himself  is  an  opportune  and 
most  useful  book,  which  cannot  fail  to  exert  a  good 
influence  on  the  morale  and  the  business  success  of 
the  Mctlical  profession." — From  ProJ".  Roberts 
iitirt/io/oiv,  Philadelphia,  Pa. 

'I  have  read  'The  Physician  Himself  with 
pleasure — delight.  It  is  brimful  of  medical  and 
social  philosophy  ;  cverj-  doctor  in  the  land  can 
Mudy  it  with  pleasure  and  profit.  I  wi.sh  1  could 
Iiave  read  such  a  work  thirty  years  ago." — From 
Pro/.  John  S.  Lynch,  Baltimore.  Md. 

"'The  Physician  Himself  interested  me  so 
much  that  1  actually  read  it  through  at  one  sitting. 
It  is  brimful  of  the  very  best  advice  possible  for 
iiicxlical  men.  I,  for  one,  shall  try  to  prolit  by  it." — 
From  Pro/.   William  Goodell,  Philadelphia. 

•'  I  .would  be  glad  if,  in  the  true  interest  of  the 
profession  in  'Old  England,'  some  able  practitioner 
here  would  prepare  a  work  for  us  on  the  same  line  as 
■The  Physician  Himself.'" — From  Dr.  Jukes  de 
Styrap,  Shreiusbury,  England. 

"  1  am  most  favorably  impressed  with  the 
wisdom  and  force  of  the  points  made  in  '  The  Phy- 
sician Himself,'  and  believe  the  work  in  the  hands 
of  a  young  graduate  will  greatly  enhance  his  chances 
for  profe.ssional  success." — From  Pro/.  D.  Hayes 
Agne'tu,  Philadelphia,  Pa. 

"  This  book  is  evidently  the  production  of  an 
unspoiled  mind  and  the  fruit  of  a  ripe  career.  1 
aiimire  its  pure  tone  and  feel  the  value  of  its  practi- 
cal points.  How  1  wish  I  could  have  read  such  a 
guide  at  the  outset  of  my  career!" — Frotn  Pro/. 
James  Nezdns  Hyde,  Chicago,  III. 

"  It  contains  a  great  deal  of  good  sense,  well 
expressed.'' — Froi>i  Pro/.  Oliver  Wendell  Holmes, 
Har'i'ard  University. 


"  'The  Physician  Himself  is  useful  alike  to  the 
tyro  and  the  sage — the  neophyte  and  the  veteran.  It 
is  a  headlight  in  the  splendor  of  whose  beams  a 
multitude  of  our  profession  shall  find  their  way  to 
success." — Froi>!  Pro/.  J.  Jif.  Bodine,  Dean  Uni- 
versity o/  Louisz'ille. 

"  It  is  replete  with  good  sense  and  sound  phi- 
losophy. No  man  can  read  it  without  realizing  that 
its  author  is  a  Christian,  a  gentleman,  and  a  shrewd 
observer." — From  Pro/.  Edivard  Warj-en  (Bey), 
Chevalier  o/ the  Legion  o/  Honor,  etc..  Paris, 
France. 

"I  have  read  'The  Physician  Himself,'  care- 
fully. I  find  it  an  admirable  work,  and  shall  advise 
our  Janitor  to  keep  a  stock  on  hand  in  the  book  de- 
partment of  Bellevue." — From  Pro/.  U'illiam  T. 
Lusk,  New  York. 

"  It  must  impress  all  its  readers  with  the  belief 
that  it  was  written  by  an  able  and  honest  member  of 
the  profession  and  for  the  good  of  the  profession." — 
From  Pro/   W.  H.  By/ord,  Chicago,  III. 

"It  is  marked  with  good  common  sense,  and 
replete  with  e.Kcellent  maxims  and  suggestions  for 
the  guidanceof  medical  men." — From  The  British 
Medical  Journal,  London. 

"  We  strongly  advise  every  actual  and  intend- 
ing practitioner  of  medicine  or  surgery  to  have 
'  The  Physician  Himself,'  and  the  more  it  influences 
his  future  conduct  the  better  he  will  be." — From 
The  Canada  Medical  and  Surgical  Journal, 
Montreal. 

"We  would  advise  every  doctor  to  well  w^h 
the  p.dvise  given  in  this  book,  and  govern  his  con- 
duct accordingly." — From  The  Virginia  Medical 
Monthly. 


(F  A.  DAVIS,  Medical  Publisher,  Philadelphia.  Pa..  USA.) 


AN  IMPORTANT  PUBLICATION  OF  GREAT  VALUE  TO  THE  MEDICAL 
AND   LEGAL    PROFESSIONS. 

Spinal  Concussion: 

Surgically  Considered  as  a  Cause  of  Spinal  Injury,  and  Neurologi- 

cally  Restricted  to  a  Certain  Symptom  Group,  for 

which  is  Suggested  the  Designation 

ERICHSEN'S  DISEASE,  AS  ONE  FORM  OF  THE  TRAUMATIC  NEUROSES. 


S.   V.    CLEVENOER,   1S/I.I3., 

CONSULTING   PHYSICIAN    REESE    AND   ALBXIAN    HOSPITALS;     LATE    PATHOLOGIST    COUNTY    INSANE   ASYLUM, 

CHICAGO;    MEMBER  OF  NUMEROUS  AMERICAN  SCIENTIFIC  AND  MEDICAL  SOCIETIES;    COLLABORATOR 

AMERICAN     NATURALIST,   ALIENIST     AND     NEUROLOGIST,    JOURNAL    OF    NEUROLOGY    AND 

PSYCHIATRY,  JOURNAL  OF  NERVOIS  AND  MENTAL  DISEASES;    AUTHOR  OF  "COM- 

PARA  TIVE  PHYSIOLOGY  AND  PSYCHOLOGY,"   "ARTISTIC   ANATOMY,"   ETC. 


For  more  thuu  twenty  years  this  sul)ject  has  occasioned  Idttoi'  con- 
tention in  law  courts,  between  physicians  as  well  as  attorneys,  and  in 
that  time  no  work  has  appeared  that  reviewed  the  entire  field  jndicially 
until  Dr.  Clevenger's  book  Was  written.  It  is  the  outcome  of  five  years' 
special  study  and  experience  in  legal  circles,  clinics,  hospital  and  private 
practice,  in  addition  to  twenty  years'  labor  as  a  scientific  student,  writ^n-, 
and  teacher. 

The  literature  of  Spinal  Concussion  has  been  increasing  of  late  years 
to  Jin  unwieldy  shape  for  the  general  student,  and  Dr.  Clevenger  has  in  this 
work  arranged  and  reviewed  all  that  has  been  done  by  obsei'vers  sinci- 
the  days  of  Erichsen  and  those  who  preceded  him.  The  dificrent  and 
sometimes  antagonistic  views  of  many  authors  are  fully  given  from  tiic 
writings  of  Erichsen,  Page,  Oppenheim,  Erb,  Westphal,  Abercrouibit-. 
Sir  Astley  Cooper,  Boyer,  Charcot,  Leyden,  Rigler,  Spitzkn.  Putnam, 
Knapp,  Dana,  and  many  otlier  European  and  American  students  of  the 
subject.  The  small,  but  important,  work  of  Oppenheim,  of  tiie  Berlin 
University,  is  fully  translated,  and  constitutes  a  chapter  of  Dr.  Cleven- 
ger's book,  and  reference  is  made  wherever  discussions  occurred  in 
American  medico-legal  societies. 

There  are  abundant  illustrations,  particularly  for  Electro-diagnosis, 
and  to  enable  a  clear  comprehension  of  the  anatomical  and  pathological 
relations. 

The  Chapters  are :  1.  Historical  Introduction ;  II.  Erichsen  on 
Spinal  Concussion  ;  III.  Page  on  Injuries  of  the  Spine  and  Spinal  Cord; 
lY.  Recent  Discussions  of  Spinal  Concussion  :  V.  Oppenheim  on  Ti-au- 
matic  Neuroses;  Ti.  Illustrative  Cases  from  Original  and  all  other 
Sources;  VII.  Traumatic  Insanity;  YIII.  The  Spinal  Column;  IX. 
Symptoms;  X.  Diagnosis;  XI.  Pathology;  XII.  Treatment;  XIII. 
Medico-legal  Considerations. 

Other  special  features  consist  in  a  description  of  modern  methods 
of  diagnosis  b}^  Electricity,  a  discussion  of  the  controversy  concerning 
hysteria,  and  the  author's  original  pathological  view  that  the  lesion  is 
one  involving  the  spinal  sympathetic  nervous  system.  In  this  latter 
respect  entireh'  new  ground  is  taken,  and  the  diversity  of  opinion  con- 
cerning the  functional  and  organic  nature  of  the  disease  is  afforded  a 
basis  for  reconciliation. 

Ereri/  Phi/i^iciav  and  Lawyer  should  own  this  work-. 

In  one  handsome  Royal  Octavo  Volume  of  nearly  400  pages,  with 
Thirty  Wood-Engravings.  Net  price,  in  United  States  and  Canada, 
$2.50,  post-paid  ;  in  Great  Britain,  lis.  3d. ;  in  France,  15  fr. 


CF.  A.   DAVIS.   Medical  Publisher.  Philadelphia,  Pa..   U.S.A.) 


JUST  READY-A  NEW  AND  IMPORTANT  WORK. 

-^^^^^^^^  K  S  S  AY 


MEDICAL  PNEDMAT0L06YIAER0THERAPY: 

A  PRACTICAL  INVESTIGATION  OF  THE  CLINICAL  AND  THERAPEUTIC  VALUE 

OF  THE  GASES  IN  MEDICAL  AND  SURGICAL  PRACTICE,  WITH  ESPECIAL 

REFERENCE  TO  THE  VALUE  AND  AVAILABILITY  OF 

OXYGEN,  NITROGEN,  HYDROGEN,  AND  NITROGEN  MONOXIDE. 

By  d.   M.   DEMARQUAY, 

Surgeon  to  the  Municipal  Hospital,  Paris,  and  of  the  Council  of  State  ;  Member  of  the  Imperial  Society 

of  Surgery;  Correspondent  of  the  Academies  of  Belgium,  Turin,  Munich,  etc.  ;  Officer 

of  the  Legion  of  Honor  ;  Chevalier  of  the  Orders  of  Isabella-the- 

Catholic  and  of  the  Conception,  of  Portugal,  etc. 

TRANSLATED.   WITH  NOTES,  ADDITIONS,  AND  OMISSIONS, 

By    SAMUEL   8.   WALLIAN,   A.M.,    M.D., 

Member  of  the  American  Medical  Association  ;  Ex-President  of  the  Medical  Association  of  Northern  New 
York  ;  Member  of  the  New  York  Coimty  Medical  Society,  etc. 


In  one  Handsome  Octavo  Volume  of  316  Pages,  Printed  on  Fine  Paper,  iu  tbe  Best 
Style  of  the  Printer's  Art,  and  Illustrated  with  21  Wood-Cuts. 

Unit«d  State.?.        Canada  (duty  paiiU.        Great  Britain.  France. 

NET  PRICE,  CLOTH,  Post-paid,        $2.00  S3. 20  8s.  6d.  12  fr.  40 

^-RUSSIA,      "  3.00  3.30'  13s.  18  fr.  60 


For  some  years  past  there  has  been  a  growing  demand  for  something  more  satisfac- 
tory and  more  practical  in  the  way  of  literature  on  the  subject  of  what  has,  by  common 
consent,  come  to  be  termed  '"  Oxygen  Therapeutics."  On  all  sides  professional  men  of 
standing  and  ability  are  turning  their  attention  to  the  use  of  the  gaseous  elements  about 
us  as  remedies  in  disease,  as  well  as  sustainers  in  health.  In  prosecuting  their  inquiries, 
•the  first  hindrance  has  been  the  want  of  any  reliable,  or  iu  any  degree  satisfactory, 
literature  on  the  subject. 

Purged  of  the  much  quackery  heretofore  associated  with  it,  Aerotherapj-  is  now 
recognized  as  a  legitimate  department  of  medical  practice.  Although  little  noise  is  made 
about  it,  the  use  of  Oxygen  Gas  as  a  remedy  has  increased  in  this  country  within  a  few- 
years  to  such  an  extent  that  in  New  York  City  alone  the  consumption  for  medical  ]'ur- 
poses  now  amounts  to  more  than  300,000  gallons  per  annum. 

This  work,  translated  in  the  main  from  the  French  of  Professor  Demarquay,  contains 
also  a  very  full  account  of  recent  English,  German,  and  American  experiences,  prepared 
by  Dr.  Samuel  S.  Wallian,  of  New  York,  whose  experience  in  this  field  antedates  that  of 
any  other  American  writer  on  the  subject. 


Plain  Talks  on  Avoided  Subjects. 

— BY —  < 

HENRY  N.  GUERNSEY,  M.D., 

Formerly  Professor  of  Materia  Medica  and  Institutes  in  the  Hahnemann  Medical  College  of  Philadelphia; 

Author  of  Guernsey's  "  Obstetrics,"  including  the  Disorders  Peculiar  to  Women  and 

Young  Children  ;  Lectures  on  Materia  Medica,  etc. 


IN  ONK  NEAT  16mo  VOLUME.     BOUND  IN  EXTRA  CLOTH.     Price,  Post-paid,  is 
United  States  and  Canada,  $1.00;  Great  Britain,  48.  6d.;  France,  6  fr.  20. 


This  is  a  little  volume  designed  to  convey  information  upon  one  of  the  most  important  subjects  con- 
nected with  our  physical  and  spiritual  well-being,  and  is  adapted  to  both  sexes  and  all  ages  and  conditions 
of  society  ;  in  fact,  so  broad  is  its  scope  thai  no  human  being  can  well  afford  to  be  without  it,  and  so  com- 
prehensive in  its  teachings  that,  no  matter  how  well  informed  one  may  be,  something  can  yet  be  learned  from 
this,  and  yet  it  is  so  plain  that  any  one  who  can  read  at  all  can  fully  understand  its  meaning. 

The  Author,  Dr.  H.  N.  Guernsey,  has  had  an  unusually  long  and  extensive  practice,  and  his  teachiags  in 
this  volume  are  the  results  of  his  observation  and  actual  experience  with  all  conditions  wf  human  life. 

His  work  is  warmly  indorsed  by  many  leading  men  in  all  branches  of  professional  life,  as  well  as  by 
many  whose  business  connections  have  caused  them  to  be  close  observers. 

The  following  Table  of  Contents  shows  the  scope  of  the  book: — 

CONTENTS.     Chapter  L— Introditctory.     H.— The  Lnfant.     IIL — Childhood.     IV.— Adolbs- 

CENCB  OF   THE   MaLE.       V. — ADOLESCENCE   OF    THE   FeMALE.       VL — MARRIAGE  :  ThE   HUSBAND.       VIL  — 

"^'he  Wife.     VIIL— Husband  and  Wife.     IX. — To  the  Unfortunate.     X.— Origin  o*  the  Sex. 

CF.  A.  DAVIS,  Medical  Publisher,  Philadelphia.  Pa..  U.S.A.)  7 


•NB^W    BOIXIOB{= 


Lessons  in  Gynecology. 

By  WILLIAM  GOODELL,  A.M.,  M.D.,  Etc., 

Phofkssor  op  Clinical  Gynecology  in  thb  University  of  Pennsylvania. 

With  112  Illaatrations.     Third  Edition,  Thorong:hly  Revised  and  Greatly  Knlarged. 
ONK  VOLUMK,  LAKGE  OCTAVO,   578  PAGES. 


This  exceedingly  valuable  work,  from  one  of  the  most  eminent  specialists  and  teachers  in  gynecology 
in  the  United  States,  is  now  offered  to  the  profession  in  a  much  more  complete  condition  than  either  of  the 
previous  editions.  It  embraces  all  the  more  important  diseases  and  the  principal  operationsjn  the  field  of 
gynecology,  and  brings  to  bear  upon  them  all  the  extensive  pr.ictic.il  experience  and  wide  reading  of  the 
;uithor.  It  is  an  indispensable  guide  to  every  practitioner  who  has  to  do  with  the  diseases  peculiar  to 
women. 

Fig.  44. 


Natural  Position  of  the  Womb  When  the  Bladder  is  Full. 
After  Briesky. 


These  lessons  are  so  well  known  that  it  is  en- 
tirely unnecessary  to  do  more  than  to  call  attention 
to  the  fact  of  the  appearance  of  the  third  edition. 
It  is  too  good  a  book  to  have  been  allowed  to  remain 
out  of  print,  and  it  has  unquestionably  been  missed. 
The  author  has  revised  the  work  with  special  care, 
adding  to  each  lesson  such  fresh  matter  as  the  prog- 
ress in  the  art  rendered  necessary,  and  he  has  en- 
larged it  by  the  insertion  of  six  new  lessons.  This 
edition  will,  without  question,  be  as  eagerly  sought 
for  as  were  its  predecessors. — American  Journal 
of  Obstetrics. 

The  former  editions  of  this  treatise  were  well 
received  by  the  profession,  and  there  is  no  doubt 
that  the  new  matter  added  to  the  present  issue  makes 
it  more  useful  than  its  predecessors. — Nezv  York 
Medical  Record. 

His  literary  style  is  peculiarly  charming.    There 


is  a  directness  and  simplicity  about  it  which  is  easier 
to  admire  than  to  copy.  His  chain  of  plain  words 
and  almost  blunt  expressions,  his  familiar  compari- 
son and  homely  illustrations,  make  his  writings,  like 
his  lectures,  unusually  entertaining.  The  substance 
of  his  teachings  we  regard  as  equally  excellent. — 
Phila.  Medical  and  Su  rgical  Reporter. 

Extended  mention  of  the  contents  of  the  book  is 
unnecessary;  suffice  it  to  say  that  every  important 
disease  found  in  the  female  se.x  is  taken  up  and  dis- 
cus.sed  in  a  common-sense  kind  of  a  way  We  wisli 
every  physician  in  America  could  read  and  carrj' 
out  the  suggestions  of  the  chapter  on  "  the  sexual  re- 
lations as  causes  of  uterine  disorders — conjugal 
onanism  and  kindred  sins."  The  department  treat- 
ing of  nervous  counterfeits  of  uterine  diseases  is 
a  most  valuable  one.  —  Kansas  City  Medical 
Index. 


Price,  in  United  States  and  Canada,  Cloth,  $5.00;  Full  Sheep,  $6.00.    Biscount,  20  per 

cent.,  making  it,  net.  Cloth,  $100;  Sheep,  $180.    Postage,  27  Cents  estra.    Great 

Britain,  Cloth,  18s. ;  Sheep,  £1.2s.,  post-paid,  net.    France,  30  fr.  80. 


(F.  A.  DAVIS,  Medical  Publisher,  Philadelphia,  Pa.,  U.S.A. 


AMERICAN    RESORTS, 

WITH  NOTES  UPON  THEIR  CLIMATE. 

:By  :b"U"SZ3:i?.03z>  "w.  trjft.KEES,  jiOi..i><r.,  ixe.id., 

Jfember  of  the  Amerk'au  Association  for  the  Advancement  of   Science,   the  American  Public  Health  Association,   the 

Pennsvlvania  Historical  Society,  the  Franklin  Instilnte,  and  the  Acadeniv  of  Natural  Sciences,  Philadelphia; 

the  Society  of  Alaskan  Natural  History  and  Ethnology,  Sitka,  Alaska,  etc. 

WITH  A  TRANSLATION  FROM  THE  GERMAN,  BY  Mr.  S.  KAUFFMANN. 

Of  those  chapters  of  ''  Die  Klimate  der  Erde"  written  by  Dr.  A.  Woeikof,  of  St.  Petersburg,  Russia,  that 
relate  to  North  and  South  America  and  the  islands  and  oceans  contiguous  thereto. 


In  One  Octavo  Volume.      Handsomely   Bound   in   Cloth.      Nearly  300   Pages.      Price, 
Post-paid,  in  XT.  S.  and  Canada,  $3.00,  net.    Great  Britain,  8s.  6d.    France,  12  fr.  40. 


This  is  a  unique  and  valuable  work,  and  useful  to  physicians  in  all  parts  of  the  country.  It  is  just  such 
a  volume  as  the  Medical  Profession  have  stood  in  need  of  for  many  years.  We  mention  a  few  of  the  merits 
it  possesses:  First.  List  of  all  the  Health  Resorts  of  the  ciuntry,  arranged  according  to  their  climate. 
Second.  Contains  just  the  information  needed  by  touiists,  invalids,  and  those  who  visit  summer  or  winter 
resorts.  Third.  The  latest  and  best  large  railroad  map  for  reference.  Fourth.  It  indicates  the  climate 
each  one  should  select  for  health.  Fifth.  The  author  has  traveled  e.xtensively,  and  most  of  his  suggestions 
are  practical  in  reference  to  localities. 


Taken  altogether,  this  is  by  far  the  most  complete  ex- 
position of  the  subject  of  resorts  tliat  has  yet  been  put 
forth,  and  it  is  one  that  every  physician  must  needs  possess 
inteliigent  information  upon.  We  predict  a  large  demand 
for  this  useful  and  attractive  book. — Buffalo  Med.  and 
Sura.  J'lur. 

Tl»o  special  chapteron  the  therjipeutics  of  climate  .  . 
is  excellent  for  its  precautionary  suggestions  in  the  selec- 
tion of  climates  and  local  conditions,  with  reference  to 
known  pathological  indications  and  constitutional  predis- 
positions.—  The  S'lnitarimi. 

It  i3  arranged  in  such  a  manner  that  it  will  be  of  great 
service  to  medical  men  whose  duty  it  often  becomes  to  rec- 
ommend a  health  resort. — i\".  VT.  )Ied.  Jour. 

A  well-arranged  map  of  the  United  States  serves  as  the 
frontispiece  of  the  book ;  and  an  almost  perfect  index  is 
appended,  while  between  the  two  is  an  amount  of  informa- 
tion as  to  places  for  the  health-seeker  that  cannot  be  gotten 
elsewhere.  We  most  cordially  recommend  the  book  to 
travelers  and  to  the  doctor. —  Viryinia  Med.  Monthli/. 

Tliis  is  a  work  that  has  long  been  needed,  as  there  is 
scarcely  a  physician  who  has  not  had  occasion  to  look  up 
the  autliorities  on  climate,  elevation,  dryness,  humidity, 
etc  ,  etc.,  of  the  various  health  resorts,  and  has  h.id  great 
difficulty  in  finding  reliable  information.     It  certainly 


ought,  as  it  deserves,  to  receive  a  hearty  welcome  from  the 
profession. — Medicaf  Advrtjice. 

The  book  before  us  is  a  very  comprehensive  volume, 
giving  all  necessary  information  concerning  climate,  tem- 
perature, humidity,  sunshine,  and  indeed  everything  neces- 
sary to  be  stated  for  tlie  benefit  of  the  physician  or  invalid 
seeking  a  health  resort  in  the  United  States. — Soutlieni 
Clinir. 

This  work  is  extremely  valuable,  owing  to  the  liberal 
and  accurate  manner  in  which  it  gives  information  regard- 
ing the  v.arious  resorts  on  the  A.nerican  continent,  without 
being  prejudiced  in  the  least  in  favor  of  any  particular  one, 
but  giving  all  in  a  fair  manner.  .  .  .  All  physicians 
need  just  such  a  work,  for  the  doctor  is  always  asked  to 
give  information  on  the  subject  to  his  patients.  Therefore, 
it  should  find  a  place  in  every  physician's  library.— r/ie 
Med.  Brief. 

The  author  of  this  admirable  work  has  long  made  a 
study  of  American  climate,  from  the  stand-point  of  a  phy- 
sician, with  a  view  to  ascertaining  the  most  suitable  locali- 
ties for  the  residence  of  invalids,  believing  proper  climate 
to  be  an  almost  indispensable  factor  in  the  treatment,  pre- 
vention, and  cure  of  many  forms  of  disease.  .  .  .  The 
book  evidences  careful  research  and  furnishes  much  useful 
information  not  to  be  found  elsewhere. — Pacific  Med.  J  Air. 


JUST    PUBLISHED  — 


RECORD-BOOK  OF  MEDICAL  EXAMINATIONS 

For  Life  Insurance. 


In  exaraiuing  for  Life  Insurance,  questions  are  easily  overlooked  and  the  answers  to 
them  omitted ;  and,  as  these  questions  are  indispensable,  they  must  be  answered  before  the 
case  can  be  acted  upon,  and  the  examiner  is  often  put  to  much  inconvenience  to  obtain 
this  information. 

The  need  has  long  been  felt  among  examiners  for  a  reference-book  in  which  could  be 
noted  the  principal  points  of  an  examination,  and  thereby  obviate  the  necessity  of  a 
second  visit  to  the  applicant  when  further  information  is  required. 

After  a  careful  study  of  all  the  forms  of  examination  blanks  now  used  by  Insurance 
Companies,  Dr.  J.  M.  Keating  has  compiled  such  a  record-book  which  we  are  sure  will  fill 
this  long-felt  want. 

This  record-book  is  small,  neat,  and  complete,  and  embraces  all  the  principal  points 
that  are  required  by  the  different  companies.  It  is  made  in  two  sizes,  viz.  :  No.  1,  cover- 
ing one  hundred  (100)  examinations,  and  No.  2,  covering  two  hundred  (200)  examina- 
tions. The  size  of  the  book  is  7x3|  inches,  and  can  be  conveniently  carried  in  tlie' 
pocket.  

NET    Mt-ICBS,    POST-PAID, 

U.  S.  and  Canada.        Great  Britain.  France. 

No.  1,  For  100  Examinations,  in  Cloth,         -         $  .50  2s.  6d.  3  l"r.  60 

No.  2,  For  200  Kxaminations,    in   Full 

Lieather,  with  Side  Flap,  .       .       -        .        1.00  4s.  6d.  6  fr.  20 


(F.  A.  DAVIS,  Medical  Publisher.  Philadelphia,  Pa.,  U.S  A.) 


■DISEASES' 


Heart  and  Circulation 

IN  INFANCY  AND  ADOLESCENCE. 

l^itlt  an  Appendix  entitled  '^  Clinical  Studies  on  the 
Pulse  in  Childhood.'' 

BV — 

JOHN   M.   KEATING,  M.D., 

•bsleirician  to  the  Philadeljihia  Hospital,  and  Lecturer  on  Diseases  of  Women  and  Children;  Surgeon  to;' 

the  Maternity  Hospital  ;  Physician  to  St.  Joseph's  Hospital;   Fellow  of  the 

College  of  Physicians  of  Philadelphia,  etc., 


WILLIAM  A.  EDAVARDS,  M.D., 

Instructor  in  Clinical  Medicine  and  Physician  to  (he  Medical  Dispensary  in  the  University  of  Pennsylvania  ; 

Physician  to  St.  Joseph's  Hospital  ;   Fellow  of  the  College  of  Physicians  ;   formerly 

Assistant  Pathologist  to  the  Philadelphia  Hospital,  etc. 


ILLUSTRATED  BY  PHOTOGRAPHS  AND  WOOD-ENGRAVINGS. 

About  225  Pages.    8vo.    Bound  in  Cloth.    Price,  post-paid,  in  U.  S, 
and  Canada,  $1.50,  net;  Great  Britain,  6s.  6d. ;  France,  9  fr.  35. 


There  are  many  excellent  text-books  on  children's  diseases,  but  they  have  failed  to  give  a  satisfactory 
.-.ccoimt  of  the  diseases  of  the  heart  ;  and,  indeed,  as  far  as  known,  this  work  of  Keating  and  Edwards'  n  jw 
presented  to  the  profession  is  the  only  systematic  attempt  that  has  been  made  to  collect  in  book  form  the 
abundant  material  which  is  scattered  throughout  medical  literature  in  the  form  of  journal  articles,  clinical 
lectures,  theses,  and  reports  of  societies. 

The  authors  have  endeavored,  in  their  difficult  task,  to  collect  these  valuable  materials  and  place  them 
within  easy  reach  of  those  who  are  interested  in  this  important  subject.  That  they  have  succeeded  will,  we 
believe, be  conceded  by  all  who  obtain  and  make  use  of  their  very  valuable  contribution  to  this  hitherto- 
neglected  field  of  medical  literature. 

An  appendix,  entitled  "  Clinical  Studies  on  the  Pulse  in  Childhood,"  follows  the  index  in  the  book,  and 
will,  we  are  sure,  be  found  of  much  real  value  to  every  practitionerof  medicine.  The  work  is  made  available 
for  ready  reference  by  a  well-arranged  index.  We  append  the  table  of  contents  showing  the  scope  of  the 
book : — 


Chapter  I — The  Methods  of  Study — Instruments — 
Foetal  Circulation — Congenital  Diseases  of  the 
Heart — Malformations — Cyanosis. 

Ch.\pter  II. — Acute  and  Chronic  Endocarditis — 
Ulcerative  endocarditis. 

Chapter  IH. — Acute  and  Chronic  Pericarditis. 

Chapter  IV. — The  treatment  of  Endo-  and  Peri- 
carditis— Paracentesis  Pericardii — Hydropericar- 
dium — Hsmopericardium — Pneumopericardium. 

Chapter  V. — Myocarditis — Tumors,  New  Growths, 
and  Parasites 

Chapter  VI.— Valvular  Di,sease:  Mitral,  Aortic, 
Pulmonary,  and  Tricuspid. 


Chapter  VII. — General  Diagnosis,  Prognosis,  and 
Treatment  of  Valvular  I^isease. 

Chapter  VIII. —  Endocarditis — Atheroma  —  Aneu- 
rism. 

Chapter  IX. — Cardiac  Neuroses — Angina  Pectoris- 
— Exophthalmic  Goitre. 

Chapter  X. — Diseases  of  the  Blood:  Plethora, 
Anaemia,  (chlorosis,  Pernicious  Ansemia,  l.eu- 
ka;mia--Hodgkin's  Disease — Ha:mophilia, Throm- 
bosis, and  Embolism. 

INDEX. 

APPENDIX.— Clinical  Studies  on  the  Pulse 
IN  Childhood. 


Drs.  Keating  and  Edwards  have  produced  a  work  that 
will  pive  material  aid  to  every  doctor  in  hi.s  practice  among 
clnldreii.  The  style  of  the  book  is  graphic  and  pleasmg, 
the  diagnostic  points  are  explicit  and  exact,  and  the  thera- 
peutical resources  include  the  noveltie.s  of  medicine  as  well 
as  the  old  and  tried  agentn.—Piflshin-i/h  Med.  Review. 

A  very  attractive  and  v.ilnalile  work  has  been  given  to 
the  medical  profe.isinn  by  Drs.  Keating  and  Edwards,  in 
their  treatise  on  the  diseases  of  the  heart  and  circulation 
in  infan(\-  and  adolescence,  and  they  deserve  the  greatest 
credit  for  tlie  admirable  nuinner  iu  which  they  have  col- 
lected, reviewed,  and  made  use  of  the  immense  amount;  of 
material  on  this  important  suhieat.— A  lyhh'rs  of  Pediatrics. 

Tlie  plan  uf  the  work  is  the  correct  one,  viz..  the  sup- 
plamentin,!!  of  the  observations  of  the  better  class  of  prae- 
titioiier.s  by  the  exjierience  of  those  who  have  given  tlie 
subject  systematic  attention. — Medical  Age. 


It  is  not  a  mere  compilation,  but  a  systematic  treatise, 
and  bears  evidence  of  considerable  labor  "and  observation  on» 
the  part  of  the  authors.  Two  fine  photographs  of  dissec- 
tions exhibit  mitral  stenosis  and  mitral  regurgitation : 
there  are  also  a  number  of  wood-cuts. — Cleveland  Medical 
Gazette. 

As  the  works  upon  diseases  of  children  give  little  or  no 
attention  to  diseases  of  the  heart,  this  work  of  Drs.  Keat- 
ing and  Edwards  will  supply  a  want.  We  think  that 
there  will  be  no  physician,  who  takes  an  interest  in  the 
affections  of  young'folks,  who  will  not  wish  to  consult  it. 
— Cincinnati  Med.  A'ews. 

The  work  t.akes  up,  in  an  able  .ind  scientific  manner, 
diseases  of  the  heart  in  children.  This  is  a  part  of  the 
field  of  medical  science  which  has  not  been  cultivated  t»' 
the  extent  that  the  importance  of  the  subject  deserves.— 
Canada  Lancet. 


(F.  A.  DAVIS,  Medical  Publisher,  Philadelphia,  Pa.,  U.S.A.) 


PERPETUAL  CLINICAL  INDEX 

— TO — 

MATERIA    MEDICA,   CHEMISTRY,    AND   PHARMACY  CHARTS. 
By  A.  H.  KELLER,  Ph.G.,  M.D. 

Coiibisting    of   (1)    the  "Perpetual  Clinical   Index,"  an   oblong    volume,    9x6    inches^ 
neatly  bound  in  extra  Cloth  ;  (2)  a  Chart  of  "Materia  Medica,"  33x44  inches, 
uiounted  ou  uiuslin,  Avith  rollers  ;  (3)  a  Chart  of  "  Chemistry  and  Phar- 
macy," 33x44  inches,  mounted  on  muslin,  with  rollers. 

France. 

30  fr.  30 


Wet  Price  for  the  Complete  Work,       $5.00 


United  States.        Canada  (duty  paid).        Great  Britain. 


$5.50 


£l.ls. 


Read  the  Following  Description  and  Explanation  of  the  Work : 

In  presenting  the  objects  and  advantages  of  these  Charts  and  "  Perpetual  Clinical  Index  "  it  becomes 
■ecessary  to  state  that  the  Author's  many  years'  e-xperience  as  a  physician  and  Pharmacist  enables  him 
tb  produce,  in  terse  language,  a  volume  of  facts  that  must  be  of  inestimable  value  to  the  busy  physician  and 
pharmacist,  or  to  any  student  of  either  profession.  He  has  endeavored  to  describe  all  that  have  borne  inves- 
tigation up  to  date. 

The  system  will  prove  to  be  of  great  value  in  this,  that  so  little  labor  will  be  required  to  add  new 
investigation  as  fast  as  may  be  gathered  from  new  books,  journals,  etc.  The  classification  is  alphabetical 
and  numeric.il  in  arrangement,  and  serves  so  to  unite  the  various  essentials  of  Botany,  Chemistry,  and 
Materia  Medica,  that  the  very  thought  of  the  one  will  readily  associate  the  principal  properties  and  uses,  as 
well  as  its  origin. 

The  "MATERIA  MEDICA"  CHART,  in  the  first  place,  aids  at  a  glance:  ist,  Botanical  or 
U.  S.  P.  Name;  2d,  The  Common  Name;  i,d,  Natural  Order;  4th,  Where  Indigenous;  5th,  Principal  Con- 
stituent; 6th,  Part  Used — herbs,  leaves,  flowers,  roots,  barks,  etc.  ;  7th,  Medicinal  Properties — mainly  con- 
sidered; 8th,  The  Pose — medium  and  large. 

On  this  Chart  there  are  475  first  names  ;  Section  A.  is  numbered  from  i  to  5g,  each  section  commencing 
with  the  capital  letter,  and  having  its  own  numbers  on  both  left-hand  and  right-hand  columns,  to  prevent 
mistakes  in  lining  out,  all  in  quite  large  tyoe.  In  the  centre  of  the  Chart,  occupying  about  6  inches  in 
width,  is  a  term  index  of  common  names.     In  the  second  column  of  Chart,  like  this  : 

Aconite  Leaves, 4  A. 

Then  by  reference  to  4  A  in  first  column,  you  there  find  the  Botanical  or  U.  S.  P.  Name.     On  this  Chart  is 
also  found  a  brief  definition  of  the  terms  used,  under  the  heading  "  Medicinal  Properties." 

The  "CHEMISTRY"  CHART  takes  in  regular  order  the  U.  S.  Pharmacoposia  Chemicals,  with 
the  addition  of  many  new  ones,  and  following  the  name,  the  Chemical  Formula,  the  Molecular  Weight,  and 
*e.\t  the  Origin.  This  is  a  brief  but  accurate  description  of  the  essential  points  in  the  manufacture  :  The 
Dose,  medium  and  large;  next.  Specific  Gravity;  then,  whether  Salt  or  Alkaloid;  next.  Solubilities,  by 
abbreviation,  in  Water,  Alcohol,  and  Glycerine,  and  blank  columns  for  solubilities,  as  desired. 

Alkaloids  and  Concentrations  are  tabulated  with  reference  numbers  for  the  Perpetual  Clinical  Index, giving 
Medicinal  Properties,  Minute  Dose  and  Large  Dose      For  example.  Alkaloids  and  Concentrations: 


Medicinal  Properties. 


Minute  Dose. 


(a)  Aconitine. 


Narcotic  and  Apyretic. 


Large  Dose. 


1-16  gr. 


Following  this.  Preparations  of  the  Pharmacopoeia,  each  tabulated.     For  example  : 

TINCTURAL. 


Tinctura. 

Drug. 

Amount.                      Alcohol. 

Dose. 

*  Aconiti. 

J  Aconite. 

I  Tartaric  Acid,  60  t  P. 

S]4  oz.  to  24  gr. 

100 

I  to  3  drops. 

■  (K)  Fineness  of  Po^\der  as  per  U.  S.  P. 
t  P.  Macerate  24  hours.    Percolate,  adding  Menstruum  to  complete  (1)  pint  tincture. 


They  are  all  thus  abbreviated,  with  a  ready  reference  head-note. 

Next,  Thermometers,  Metric  Table  of  Weights,  Helps  to  the  Study  of  Chemistry,  Examples  in  Work- 
ing Atomic  Molecular  Formula;.  Next,  Explanation  of  Terms  Used  in  Columns  of  Solubilities,  List  of 
Most  Important  Elements  Now  in  Use,  and  Definitions  or  Terms  Frequently  Used  in  Chemistry  and 
Pharmacy. 

The  "PERPETUAL,  CLINICAL,  INDEX"  is  a  book  6  by  9  inches,  and  one- half  inch  thick. 
It  contains  135  pages,  divided  as  follows  (opposite  pages  blank)  : 

The  Index  to  Chemistry  Chart  occupies  two  pages;  Explanations,  Abbreviations,  etc.,  forty  pages,  with 
disea-ses,  and  with  an  average  of  ten  references  to  each  disease,  leaving  room  for  aboi«  forty  more  remedies 
for  each  disease.  The  numbers  refer  to  the  remedies  used  in  the  diseases  by  the  most  celebrated  physicians 
and  surgeons,  and  the  abbreviations  to  the  manner  in  which  they  are  used.  Eight  pages,  numbered  and 
bracketed,  for  other  diseases  not  enumerated.  The  Materia  Medica,  Explanations,  Abbreviations,  and 
Remedies  suggested  for,  occupy  twenty-six  pages.  P'or  Abbreviated  Prescriptions,  seventeen  blank  pages. 
Then  the  Index  to  Alkaloids  and  Concentrations.  These,  already  enimierated,  with  their  reference,  number 
six  blank  tabulated  pages,  for  noting  any  new  Alkaloids  and  Concentrations.  Then  the  Chemistry  Inde.x, 
giving  the  same  number  as  on  Chart,  with  Name,  Doses,  Specific  Gravity,  Salt  or  Alkaloid  in  the  same 
line,  as  for  example  : 


Name. 


Doses. 


Specific  Gravity. 


Salt  or  Alkaloid. 


Memoranda. 


This  Memoranda  place  is  for  Physicians'  or  Pharmacists'  reference  notes ;  and  with  the  addition  of 
several  tabulated  blank  pages,  in  which  to  add  any  new  chemical,  with  doses,  etc.  The  remaining  sixteen 
pages  for  Materia  Medica  Index,  leaving  blanks  following  each  other  for  new  names  and  reference  numbers. 

To  show  the  ready  and  permanent  use  of  the  "Perpetual  Clinical  Index"  of  the  "Chemistry"  and 
"Pharmacy"  Charts  or  Index  in  the  book,  suppose  the  Physician  reads  in  a  book  or  journal  thai  Caffeine 
Citras  is  useful  in  the  disease  Chorea,  and  he  wishes  to  keep  a  permanent  record  of  that,  he  refers  to  the 
Chart ,  and  if  it  does  not  already  appear  there,  it  can  be  placed  opposite  and  numbered,  and  thereafter  used 
for  reference.  But  we  find  its  permanent  number  is  No.  99,  so  he  will  write  down  in  the  line  left  blank  for 
future  use  in  his  book,  in  line  already  used,  ruling  parallel  with  other  reference  numbers  in  Chorea,  the 
No.  99.  and  immediately  under  he  can  use  the  abbreviation  in  the  manner  in  which  it  is  given.  Though 
years  may  have  passed,  he  can  in  a  moment,  by  referring  there,  see  that  No.  99  is  good  for  Chorea.  If  fail- 
ing to  remember  what  No.  99  is,  he  glances  at  the  Chart  or  Index.  He  sees  that  No.  99  is  Caffeine  Citras, 
and  he  there  learns  its  origin  and  dose  and  solubility,  and  in  a  moment  an  intelligent  prescription  can  be 
•onstructed. 


(F.  A.  DAVIS,  Medical  Publisher,  Philadelphia,  Pa.,  U.S. A. J 


11 


New  Edition  of  an  Important  and  Timely  Work  Just  Published. 

Electricity  in  tlie  Diseases  of  ^omen, 

With  Special  Reference  to  the  Application  of  Strong  Currents. 

By  G.  BETTON  MASSEY,  M.D., 

physician  to  the  Gynecoloi^ical  Department  of  Howard   Hospital;   Late  Electro-Therapeutist  to  the  Phila- 
delphia  ()rihopa;dic   Hospital   and    Infirmary    i'or  Nervous    Diseases;    Memlier   of  tiie  American 
Neurological  Ass'n,  of  the  Philadelphia  Neurological  Society,  of  the  Franklin  Institute,  etc. 


Seco33.a.    sa.ition..        I2,eT7-l©ed.    arid.    Ei:i.larg:ed.. 

WITH  NEW  AND  ORIGINAL  WOOD-ENGKAVINGS.     HANDSOMELY  BOUND  IN  CLOTH.     OVER  200  PAGES. 

12mo.        Price,   in  United  States  and  Canada,   $1.60,  net,   post-paid. 

In  Great  Britain,  6b.  6d.    In  France,  9  fr.  36. 


This  work  is  presented  to  the  profession  as  the  most  complete  treatise  yet  issued  on 
'lie  electrical  treatment  of  diseases  of  women,  and  is  destined  to  fill  the  increasing  demand 
■r  clear  and  practical  instruction  in  the  handling  and  use  of  strong  currents  after  the 
recent  methods  first  advocated  by  Apostoli.  The  whole  subject  is  treated  from  the  present 
stand-point  of  electric  science  with  new  and  original  illustrations,  the  thorough  studies  of 
the  author  and  his  v/ide  clinical  experience  rendering  him  an  authority  upon  electricity 
itself  and  its  therapeutic  applications.  The  author  has  enhanced  the  practical  value  of 
the  work  by  including  the  exact  details  of  treatment  and  results  in  a  number  of  cases 
taken  from  his  private  and  hospital  practice. 


Fig.  15. — Author's  Fibroid  Spear. 


Fig.  i8. — Ball  Electrode  for  Administering  Franklinic  Sparks. 


-coisrarEiLTTs- 


Chapter  I,  Introductory  ;  II,  Apparatus  required  in  gynecological  applications  of  the  galvanic  current ; 
III,  Experiments  illustrating  the  physical  qualities  of  galvanic  currents;  IV,  Action  of  concentrated  gal- 
vanic currents  on  organized  tissues  ;  V,  Intra-uterine  galvano-chemical  cauterization;  VI,  Operative  details 
of  pelvic  electro-puncture;  VII,  The  faradic  current  in  gynecology  ;  VIII,  The  franklinic  current  in  gyne- 
cology ;  IX,  Non-caustic  vaginal,  urethral,  and  rectal  applications  ;  X,  General  percutaneous  applications  in 
the  treatment  of  nervous  women  ;  XI,  The  electrical  treatment  of  fibroid  tumors  of  the  uterus  ;  XH,  The 
electrical  treatment  of  uterine  hemorrhage;  XIII,  The  electrical  treatment  of  subinvolution;  XIV,  The 
electrical  treatment  (^  chronic  endometritis  and  chronic  metritis;  XV,  The  electrical  treatment  of  chronic 
diseases  of  the  uterus  and  appendages;  XVI,  Electrical  treatment  of  pelvic  pain;  XVII,  The  electrical 
treatment  of  uterine  displacements;  XVIII,  The  electrical  treatment  of  extra-uterine  pregnancy;  XIX, 
The  electrical  treatment  of  certain  miscellaneous  conditions  ;  XX,  The  contra-indications  and  limitations  to 
the  use  of  strong  currents. 

An  Appendix  and  a  Copious  Index,  including  the  definitions  of  terms  used  in  the  work,  concludes 
the  book. 


The  author  gives  us  what  he  has  seen,  and  of  which 

he  is  assured  by  scientific  study  is  correct We 

are  certain  that  this  little  work  will  prove  helpful  to  all 
physicians  who  desire  to  use  electricity  in  the  management 
of  the  diseases  of  women. —  The  American  Lancet. 

To  say  that  the  author  is  rather  conservative  in  his 
ideas  of  tlie  curative  powers  of  electricity  is  only  another 
way  of  saying  that  he  understands  his  subject  thoroughly. 
The  mild  enthusiasm  of  our  author  is  unassailable,  because 
it  is  founded  on  science  and  reared  with  experience. — The 
Medical  Analectic. 

The  work  is  well  written,  exceedingly  practical,  and 
can  be  trusted.  We  commend  it  to  the  profession." — Mary- 
land Medical  Journal. 

The  book  is  one  which  should  be  possessed  hy  every 
physician  who  treats  diseases  of  women  by  electricity. — 
The  Brooklyn  Medical  Journal. 

The  departments  of  electro-physics,  pathology,  and 
plectro-therapeutics  are  thoroughly  and  admirably  con- 


sidered, and  by  means  of  good  wood-cuts  the  heginner  has 
before  his  eye  the  exact  method  of  work  required. — The 
Medical  Reijisler. 

"  The  author  of  this  little  volume  of  210  pages  ought 
to  have  added  to  its  title,  "  and  a  most  happy  dissertation 
upon  the  methods  of  using  this  medicinal  agent;  "  for  in 
the  first  lOU  piiges  he  has  contrived  to  describe  the  lechni 
of  electrization  in  as  clear  and  happy  a  manner  as  no 
author  has  ever  succeeded,  in  doing,  and  for  this  part  of  the 
book  alone  it  is  almost  priceless  to  the  beginner  in  the 

treatment  with  this  agent The  little  book  is 

worthy  the  perusal  of  every  one  at  all  interested  in  the 
subject  of  electricity  in  medicine. —  The  Omaha  Clinic. 

The  treatment  of  fibroid  tumor  of  the  uterus  will, 
perhaps,  interest  the  profession  more  generally  than  any 
other  question.  This  subject  has  been  accorded  ample 
space.  The  method  of  treatment  in  many  cases  has  been 
recited  in  detail,  the  results  in  every  instance  reported  be- 
ing beneficial,  and  in  many  curative.— Paci/ic  Med.  Jour. 


12 


(F.  A.  DAVIS,  Medical  Publisher,  Philadelphia,  Pa.,  U.S.A.) 


PRACTICAL  SURGERY. 

By  J.  EWING  ]»IBARS,  m.D., 

Lecturer  on  Practical  Surgery  and  Demonstrator  of  Surgery  in  Jefferson   Medical  College;    Professor  of 
Anatomy  and  Clinical  Surgery  in  the  Pennsylvania  College  of  Dental  Surgery,  etc. 


With  490  Illustrations.   Second  edition,  revised  and  enlarged.    794  pp,    12mo. 


PRICE.  IN  UNITED  STATES  AND  CANADA  :  CLOTH,  $3.00.     DISCOUNT,  20  PER  CENT.,  MAKING  IT,  NET. 
$2.40;  POSTAGE,  20  CENTS  EXTRA.     GREAT  BRITAIN,   13s.     FRANCE,  18  fr.  75. 


Mears'  Practical  Surgery  includes  chapters  on  Surgical  Dress- 
ings, Bandaging,  Fractures,  Dislocations,  Ligature  of  Arteries,  Amputa- 
tions, Excisions  of  Bones  and  Joints.  This 
work  gives  a  complete  account  of  the 
methods  of  antiseptic  surgery.  The  dif- 
ferent agents  used  in  antiseptic  dressing, 
their  methods  of  preparation,  and  their 
application  in  the  treatment  of  wounds  are 
fully  despribed.  With  this  Avork  as  a  guide 
it  is  possible  for  ever}'^  surgeon  to  practice 
antiseptic  surger3^  The  great  advances 
made  in  the  science  and  art  of  surgery'  are 
largely  due  to  the  introduction  of  anti- 
septic methods  of  wound  treatment,  and  it 
is  incumbent  upon  every  progressive  sur- 
geon to  employ  them. 

An  examination  of  this  work  will 
show  that  it  is  thoroughly  s^^stematic  in 
its  i)]au,  so  that  it  is  not  onl}^  useful  to  the  practitioner,  who  may  be 
called  upon  to  perform  operations,  but  of  great  A'alue  to  the  student  in 
his  work  in  the  surgical  room,  where  he  is  required  to  appl^y  bandages 
and  fracture  dressings,  and  to  perform  operations  upon  the  cadaver.  The 
experience  of  the  author,  derived  from  many  3'ears'  service  as  a  teacher 
(private  and  public)  and  practitioner,  has  enabled  him  to  present  the 
topics  discussed  in  such  a  manner  as  to  fully  meet  the  needs  of  both  prac- 
titioners and  students. 


It  is  full  of  common  sense,  and  may  be  safely  [ 
taken  as  a  guide  in  the  matters  of  which  it  treats,  i 
It  would  be  hard  to  point  out  all  the  excellences  of  ! 
this  book.  We  can  heartily  recommend  it  to  students  j 
and  to  practitioners  of  surgery. — Americiin  your- 
nal  0/  the  Medical  Sciences. 

We  do  not  know  of  any  other  work  which  would 
be  of  greater  value  to  the  student  in  connection  with 
his  lectures  in  this  department — Buffalo  Medical   ' 
and  Surgical  yoitrnal. 

The  work  is  excellent.      The  student   or  practi- 


tioner who  follows  it  intelligently  cannot  easily  g» 
astray. — you rnal  American  Medical  Asso'n. 

We  cannot  speak  too  highly  of  the  volume  under 
review. —  Canada  Med.  and  Surg.  your. 

The  space  devoted  to  fractures  and  dislocations 
— by  far  the  most  difficult  and  responsible  part  of 
surgery — is  ample,  and  we  notice  many  new  illustra- 
tions explanatory  of  the  te.xt. — North  Carolina 
Medical  yoitrnal. 

It  is  one  of  the  most  valuable  of  the  works  of  its 
kind. — Ne-w  Orleans  Med.  and  Surg.  your. 


(F.  A.  DAVIS,  Medical  Publisher,  Philadelphia,  Pa.,  U.S.A.) 


AN  ENTIRELY  NEW  PHYSICIANS  VISITING  LIST. 

-— -^-=  T  I-i  K 

JVIedical  Bulletin  Visiting  List 

OR 

PHYSICIAN'S  QaLL  f^ECORD. 


ARRANGED  UPON  AN  ORIGINAL  AND  CONVENIENT  MONTHLY  AND  WEEKLY  PLAN 
FOR  THE  DAILY  RECORDING  OF  PROFESSIONAL  VISITS. 


Frequent  Rewriting  of  Names  Unnecessary. 

This  Visiting  List  is  .irranged  upon  a  plan  best  adapted  to  the  most 
convenient  use  of  all  physicians,  and  embraces  a  new  feature  in  recording 
daily  visits  not  found  in  any  other  list,  consisting  of  stub  or  half  leaves 
IN  THE  FORM  OF  INSERTS,  a  glance  at  which  will  sufllce  to  show  that  as  the 
first  week's  record  of  visits  is  completed  the  next  week's  record  may  be 
made  by  simply  turning  over  the  stub-leaf,  without  the  necessity  of  re- 
writing the  patients'  names.  This  is  done  until  the  month  is  completed, 
and  the  physician  has  kept  his  record  just  as  complete  in  every  detail  of 
visit,  CHARGE,  CREDIT,  etc,  as  he  could  have  done  had  he  used  any  of  the 
old-style  visiting  lists,  and  has  also  saved  himself  three-fourths  of  the 
time  and  labor  formerly  required  in  transferring  names  every  week. 
There  are  no  intricate  rulings  ;  everything  is  easilj^  and  quickly  under- 
stood ;  not  the  least  amount  of  time  can  be  lost' in  comprehending  the 
plan,  for  it  is  acquired  at  a  glance. 

The  Three  Different  Styles  Made. 

The  Wo.  1  Style  of  this  List  provides  ample  space  for  the  daily 

record  of  seventy  (70)  different  names  each  month  for  an  entire  year 
(two  full  pages,  thirty -five  [35]  names  to  a  page,  being  allowed  to  each 
month),  so  that  its  size  is  sufficient  for  an  ordinary  practice ;  but  for 
physicians  who  pi'efer  a  List  that  will  accommodate  a  larger  practice  we 
have  made  a  iVo.  2  StylOf  which  provides  ample  space  for  the  daily 
recoi'd  of  one  hundred  and  five  different  names  (105)  each  month  for 
an  entire  year  (three  full  pages  being  allowed  to  each  month),  and  for 
physicians  who  may  prefer  a  Pocket  Record  Book  of  less  thickness  than 
either  of  these  styles  we  have  made  a  Wo.  3  Stl/lCf  in  which  "  The 
Blanks  for  the  Recording  of  Visits  In  "  have  been  made  into  removable 
sections.  These  sections  are  very  thin,  and  are  made  up  so  as  to  answer 
in  full  the  demand  of  the  largest  practice,  each  section  providing  ample 
space  for  the  daily  record  of  two  hundred  and  ten  (210)  different 
NAMES  for  one  month;  or  one  hundred  and  five  (105)  different  names 
daily  each  month  for  two  months  ;  or  seventy  (70)  different  names  daily 
each  month  for  three  months  ;  or  thirty-five  (35)  different  names  daily 
each  month  for  six  months.  Four  sets  of  these  sections  go  with  eack 
copy  of  No.  3  Style. 

Special  Features  Not  Found  in  Any  Other  List. 

In  this  No.  3  Style  the  printed  matter,  and  such  matter  as  the 
BLANK  forms  FOR  ADDRESSES  OP  Patients,  Obstetric  Record,  Vaccination 
Record,  Cash  Account,  Births  and  Deaths  Records,  etc.,  are  fastened 
permanently  in  the  back  of  the  book,  thus  reducing  its  thickness.  The 
addition  of  one  of  these  removable  sections  does  not  increase  the  size 
quite  an  eighth  of  an  inch.  This  brings  the  book  into  such  a  small  com- 
pass that  no  one  can  object  to  it  on  account  of  its  thickness,  as  its  bulk 

14 


is  VERY  MUCH  LESS  than  that  of  any  visiting  list  ever  published.  Every 
physician  will  at  once  understand  that  as  soon  as  a  section  is  full  it  can 
be  taken  out,  filed  away,  and  another  inserted  without  the  least  incon- 
venience or  trouble. 

This  Visiting  List  contains  a  Calendar  for  the  last  six  months 
of  last  year,  all  of  this,  and  next  .year;  Table  of  Signs  to  be  used 
in  Keeping  Accounts;  Dr.  Ely's  Obstetrical  Table;  Table  of  Cal- 
•culating  the  Number  of  Doses  in  a  given  H,  etc.,  etc. ;  for  convertincj 
Apothecaries'  Weights  and  Measures  into  Grammes  ;  Metrical  Avoirdu- 
pois and  Apothecaries' AVeights ;  Number  of  Drops  in  a  Fluidrachm  ; 
•Oraduated  Doses  for  Children ;  Graduated  Table  for  Administering 
Laudanum  ;  Periods  of  Eruption  of  the  Teeth  ;  The  Average  Frequency 
of  the  Pulse  at  Diflerent  Ages  in  Health ;  Formula  and  Doses  of  H^'po- 
•dermic  Medication ;  L^se  of  the  Hypodermic  Syringe ;  Formula?  and 
Doses  of  Medicine  for  Inhalation ;  Formula  for  Suppositories  for  the 
Rectum ;  The  Use  of  the  Thermometer  in  Disease  ;  Poisons  and  their 
Antidotes ;  Treatment  of  Asph3'xia ;  Auti-Emetic  Remedies ;  Nasal 
Douches ;  Eye-Washes. 

Most  Convenient  Time-  and  Labor-  Saving  List  issued. 

It  is  evident  to  every  one  that  this  is,  beyond  question,  the  best  and 
most  convenient  time-  and  labor-  saving  Physicians'  Record  Book  ever 
published.  Ph3'sicians  of  many  years'  standing  and  with  large  practices 
pronounce  this  the  Best  List  they  have  ever  seen.  It  is  handsomely 
bound  in  fine,  strong  leather,  with  flap,  including  a  pocket  for  loose 
memoranda,  etc.,  and  is  furnished  with  a  Dixon  lead-pencil  of  excellent 
•quality  and  finish.  It  is  compact  and  convenient  for  carrying  in  the 
pocket.     Size,  4  x  6|  inches. 


No. 

No. 
No. 


IK    THREE    SXYI^ES— NEX    PR.ICES,    POST-PAID. 

U.  S.  and  Canada.     Great  Britain.       France. 
Regular  Size,  for  70  patients  daily  each  month  for  one  year,        $1.26  5s.  3.  7  fr.  75 

Large  Size,  for  105  patients  daily  each  month  for  one  year,  1.50  6s.  6.  9  fr.  35 

In  which  "The  Blanks  for  Recording  Visits  in"  are  in  re- 
movable sections,  as  described  above,         ....  1.75  7s.  3.       12  fr.  30 


EXTRACTS    FROM    REVIEWS.- 


"  While  each  page  records  only  a  week's  visits, 
:yet  by  an  ingenious  deviceof  half  leaves  the  names 
•of  the  patients  require  to  be  written  but  once  a 
month,  and  a  glance  at  an  opening  of  the  book 
shows  the  entire  visits  paid  to  any  individual  in  a 
month.  It  will  be  found  a  great  convenience." — 
Boston  Medical  and  Surgical  yournal. 

"Everything  about  it  is  easily  and  quickly 
understood." — Canadian  Practitioner. 

•'Of  the  many  visiting  lists  before  the  profes- 
sion, each  has  some  special  feature  to  recommend 
it.  This  list  is  very  ingeniously  arranged,  as  by  a 
series  of  narrow  leaves  following  a  wider  one,  the 
name  of  the  patient  is  written  but  once  during  the 
month,  while  the  account  can  run  for  thirty-one 
"days,  space  being  arranged  for  a  weekly  debit 
and  credit  summary  and  for  special  memoranda. 
The  usual  pages  for  cash  account,  obstetrical 
record,  addresses,  etc.,  are  included.  A  large 
amount  of  miscellaneous'  information  is  presented 
in  a  condensed  form."  —  Occidental  Medical 
Times. 

"It  is  a  monthly  instead  of  a  weekly  record, 
thus  obviating  the  transferring  of  names  oftener 
than  once  a  month.  There  is  a  Dr.  and  Cr.  column 
following  each  week's  record,  enabling  the  doctor 
■to  carry  a  patient's  account  for  an  indefinite  time, 
-or  until  he  is  discharged,  with  little  trouble." — 
Indiana  Medical  yournal. 


"Accounts  can  begin  and  end  at  any  date. 
Each  name  can  be  entered  for  each  day  of  everj' 
month  on  the  same  line.  To  accomplish  this,  four 
leaves,  little  more  than  one-third  as  wide  as  the 
usual  leaf  of  the  book,  follow  each  page.  Oppo- 
site is  a  full  page  for  the  recording  of  special 
memoranda.  The  usual  acc&mpaniments  of  this 
class  of  books  are  made  out  with  care  and  fitness.V 
—  The  American  Lancet. 

"This  is  a  novel  list,  and  an  imusually  con- 
venient one." — Journal  0/ the  Amer.  Med.  Assoc. 

"This  new  candidate  for  the  favor  of  physi- 
cians possesses  some  unique  and  useful  points. 
The  necessity  of  rewriting  names  every  week  is 
obviated  by  a  simple  contrivance  in  the  make-up 
of  its  pages,  thus  saving  much  valuable  time, 
besides  reducing  the  bulk  of  the  book." — Buffalo 
Medica  I  and  Su  rgicad  you  ma  I. 

"This  list  is  a:\  entirely  new  departure,  and 
on  a  plan  that  renders  posting  rapid  and  easy.  It 
is  just  what  we  have  often  wished  for,  and  really 
fills  a  long-felt  want." — The  Medical  Waif. 

"  It  certainly  contains  the  largest  amount  of 
practical  knowledge  for  the  medical  practitioner 
in  the  smallest  possible  volume,  beside.*;  enabling 
the  poorest  accountant  to  keep  a  correct  record, 
and  render  a  correct  bill  at  a  moment's  notice." — 
Medical  Chips. 


(F.  A.  DAVIS,  Medical  Publisher.  Philadelphia,  Pa..  U.S.A.) 


HAND-BOOK  OF  ECLAMPSIA; 

OK, 

Notes  and  Cases  of  Puerperal  Convulsions. 


E.  MiCHENER,  M.D.,  J.  H.  Stubbs,  M.D..  R.  B.  EwiNG,  M.D., 

B.  Thompson,  M.D.,  S.  Stebbins,  M.D. 

Price,  in  United  States  and  Canada,  Bound  in  Cloth,  16mo,  Net,  75  Cents;  in  Great 
Britain,  3  Shillings;  in  France,  4  fr.  20. 

In  our  medical  colleges  the  teachers  of  Obstetrics  dwell  upou  the  use  of  blood-letting  (phlebotomy)  ia 
cases  of  puerperal  convulsions,  and  to  this  method  Dr.  Michencr  and  his  fellows  give  their  un(|ualified 
support — not  to  take  a  prescribed  number  of  ounces,  but  to  bleed/or  effect,  andy>am  a  large  ori/ice.  This 
is  plamly  and  admirably  set  forth  in  his  book.  To  bleed  requires  a  cutting  instrument, — not  necessarily  a 
lancet, — for  Dr.  M.  states  how  in  one  case  a  pocket-knife  was  used  and  the  desired  effect  produced. 

Let  the  young  physician  gather  courage  from  this  little  book,  and  let  the  more  experienced  give  testi- 
mony to  confirm  its  teaching. 


We  liave  always  thought  tliat  tliis  treatment  was 
inilor.sed,  approved,  and  i)racticed  by  physicians  generally ; 
and  to  such  as  doiiht  tlie  efficacy  of  blood-letting  we  woulU 
commend  this  little  volume. — Southern  Clinic. 

The   authors   are   seriously  striving  to  restore    the 


"lost  art"  of  blood-letting,  and  we   must  commend   the 
modesty  of  their  endeavor. — North  darolina  Mid.  .Imir. 

The  cases  were  ably  analyzed,  and  this  plea  for  vene- 
section should  receive  the  most  attentive  consideration  froih 
obstetricians. — Medical  and  Sarijirnl  Reporter. 


TTJST    I5,E-A_nD"2r.- 


A  MANUAL  OF  INSTRUCTION 

FOR  GIVING 

'""""^""""tii tease  Treatment. 


F*ROK.     HARTVia    NiSSEN, 

Director  of  the  Svi^edish  Health   Institute,   Washington,  D.C.  ;   I.ate   Instructor  in   Physical  Culture  ani 

Gymnastics  at  the  Johns  Hopkins  University,  Baltimore,  Md.  ;  Author  of 

"  Health  by  Exercise  without  Apparatus." 


ILLUSTRATED    WITH  29   ORIGINAL    WOOD-ENGRAVINGS. 


In  One  12mo  Volume  of  128  Pages.     Neatly  Bound  in  Cloth.     Price, 

post-paid,  in  United  States  and  Canada,  Net,  $1.00;  in 

Great  Britain,  4s.  3d.;  in  France,  6  fr.  20. 


This  is  the  only  publication  in  the  English  language  treating  this  very  important 
subject  in  a  practical  manner.  Full  instructions  are  given  regarding  the  mode  of 
applying 

The  Swedish  Movemeiit  and  Massage  Treatment 

in  various  diseases  and  conditions  of  the  human  system  with  the  greatest  degree  of 
effectiveness.  Professor  Nissen  is  the  best  authority  in  the  United  States  upon  this  prac- 
tical phase  of  this  subject,  and  his  book  is  indispensable  to  every  physician  who  wishes  t*- 
know  how  to  use  these  valuable  handmaids  of  medicine. 


This  manual  is  valuable  to  the  practitioner,  as  it 
contains  a  terse  description  of  a  subject  but  too  little  under- 
stood in  this  country The  book  is  got  up  very 

creditably.— if.  Y.  Med.  Jour. 

The  present  volume  is  a  modest  account  of  the  appli- 
cation of  the  Swedish  Movement  and  Massage  Treatment, 
in  which  the  technique  of  the  various  procedures  are  clearly 
stated  as  well  as  ilhistrated  in  a  very  excellent  manner. 
— North  American  Practitioner. 

This  Jittio  manual  seems  to  be  written  by  an  expert, 
and  to  those  who  desire  to  know  the  details  connected  with 


the  Swedish  Movement  and  Massage  we  commend  th» 
book. — Practice. 

This  attractive  little  book  presents  the  subject  in  a  very 
practical  shape,  and  makes  it  possible  forevery  physician  t* 
understand  at  least  how  it  is  applied,  if  it  does  not  give  hii» 
dexterity  in  the  art  of  its  application.  lie  can  certainly 
acquire  dexterity  by  following  the  directions  so  plainly  ad- 
viied  in  this  book. — Chicago  Med.  Times. 

It  is  so  practical  and  clear  in  its  demonstrations  that 
if  you  wish  a  work  of  this  nature  you  cannot  do  better  thaa. 
peruse  this  one. — Medical  Brief. 


(F.  A.  DAVIS,  Medical  Publisher,  Philadelphia,  Pa.,  U.S.A.) 


JUST  READY— THE  LATEST  AND  BEST  PHYSICIAN'S  ACCOUNT- 
BOOK  EVER  PUBLISHED. 


THE  PHYSICIAN'S 


ALL-REQai51TE  TlNE- 

AH^  Labor-  5avinq 


Account-Book: 


BEING  A  LEDGER  AND  ACCOUNT-BOOK  FOR  PHYSICIANS'  USE,  MEETING  ALL 
THE  REQUIREMENTS  OF  THE  LAW  AND  COURTS. 

DESIGNED   BY 

0£  Elaston,  ^=SL. 


PROBABLY  no  class  of  people  lose  more  money  through  carelesslj'  kept 
aceonnts  and  overlooked  or  neglected  bills  than  ph^^sicians.  Often 
detained  at  the  bedside  of  the  sick  until  late  at  night,  or  deprived  of 
even  a  modicum  of  rest,  it  is  with  great  difficulty  that  he  spares  the 
time  or  puts  himself  in  condition  to  give  the  same  care  to  his  own 
financial  interests  that  a  merchant,  a  lawj^er,  or  CA'en  a  farmer -devotes. 
It  is  then  plainly  apparent  that  a  sj^stem  of  bookkeeping  and  accounts 
that,  without  sacrificing  accuracy,  but,  on  the  other  hand,  ensuring  it,  at 
the  same  time  relieves  the  keeping  of  a  physician's  book  of  half  their 
complexity  and  two-thirds  the  labor,  is  a  convenience  which  will  be 
eagerly  welcomed  by  thousands  of  overworked  physicians.  Such  a  sys- 
tem has  at  last  been  devised,  and  we  take  pleasure  in  offering  it  to  the 
profession  in  the  form  of  The  Physician's  All-Requisite  Time-  and 
Labor-  Saving  Account-Book. 

There  is  no  exaggeration  in  stating  that  this  Account-Book  and 
Ledger  reduces  the  labor  of  keeping  your  accounts  more  than  one-half, 
and  at  the  same  time  secures  the  greatest  degree  of  accuracy.  We  may 
mention  a  few  of  the  superior  advantages  of  The  Physician's  All- 
Requisite  Time-  and  Labor-  Saying  Account-Book,  as  follow: — 


First — Will  meet  all  the  requirements  of 
the  law  and  courts. 

Second — Self-explanatory  ;  no  cipher  code. 

Third — Its  completeness  without  sacrificing 
anything. 

Fourth — No  posting ;  one  entry  only. 

Fifth — Universal ;  can  be  comnienced  at  any 
time  of  year,  and  can  be  continued  in- 
definitely until  every  account  is  filled. 

Sixth — Absolutely  no  waste  of  space. 

Seventh — One  person  must  needs  be  sick 
ever)'  day  of  the  year  to  fill  his  account, 
or  might  be  ten  years  about  it  and  re- 
quire no  more  than  the  space  for  one 
account  in  this  ledger. 

Eighth — Double  the  number  and  many  times 
more  than  the  number  of  accounts   in 


any  similar  book ;  the  300-page  book 
contains  space  for  900  accounts,  and  the 
600-page  book  contains  space  for  180d 
•   accounts. 

Ninth — There  are  no  smaller  spaces. 

Tenth — Compact  without  sacrificmg  com- 
pjleteness ;  every  account  complete  on 
same  page — a  decided  advantage  and 
recommendation. 

Eleventh — Uniform  size  of  leaves. 

Twelfth — The  statement  of  the  most  com- 
plicated account  is  at  once  before  j'ou 
at  any  time  of  month  or  year — in  other 
words,  the  account  itself  as  it  stands  is 
its  simplest  statement. 

Thirteenth — No  transferring  of  accounts, 
balances,  etc. 


To  all  physicians  desiring  a  quick,  accurate,  and  comprehensive 
method  of  keeping  their  accounts,  we  can  safel}^  say  that  no  book  as 
suitable  as  this  one  has  ever  been  devised. 


NET  PRICES,  SHIPPING  EXPENSES  PREPAID. 

No.  1.  300  Pages,  for  900  Accounts  per  Year, 

Size  10xl2,  Bound  in  i;  Russia,  Baised     '"  U.  S. 
Back-Bands,  Cloth  Sides,  .  .         .      S5.00 

No.  2.  600  Pages,  for  1800  Accounts  \>er  Year, 
.Size  10x12,  Bound  in  %  Russia,  Raised 
Back-Bands,  Cloth  Sides,         .         .         .        8.00 


Canada 
(duty  paid). 

Great 
Britain. 

France. 

$5.50 

£0.18s. 

30  fr.  3© 

8.80 

1.13s. 

49  fr.  40 

(F.  A.  DAVIS,  Medical  Publisher,  Philadelphia,  Pa.,  U.S.A.) 


17 


PHYSICIANS'  INTERPRETER 

IN   FOUR  I.ANGUAGES. 

(ENGLISH,  FRENCH,  GERMAN,  AND  ITALIAN.) 


Specially  Arranged  for  Diagnosis  by  M.  von  \, 


The  object  of  this  little  work  is  to  meet  a  need  often  keenly  felt  hj 
the  busy  physician,  namely,  the  need  of  some  quick  and  reliable  method 
of  communicating  intelligibly  with  patients  of  those  nationalities  and 
languages  mi  familiar  to  the  practitioner.  The  plan  of  the  book  is  a  sys- 
tematic arrangement  of  questions  upon  the  various  branches  of  Practical 
Medicine,  and  each  question  is  so  worded  that  the  only  answer  required 
of  the  patient  is  merely  Yes  or  No.  The  questions  are  all  numbered, 
and  a  complete  Index  renders  them  always  available  for  quick  reference. 
The  book  is  written  by  one  who  is  well  versed  in  English,  French,  Ger- 
man, and  Italian,  being  an  excellent  teacher  in  all  those  languages,  and 
who  has  also  had  considei'able  hospital  experience. 


Bound  in  Full  Russia  Leather,  for  Carrying  in  the  Pocket.  (Size,  5x2f 
Inches.)     206  Pag-es.     Price,  post-paid,  in  United  States  and 
Canada,  $1.00,  net;  Great  Britain,  4s.  6d. ;  France,  6  fr.  20.     , 


To  convej'  some  idea  of  the  scope  of  the  questions  contained  in  the 
Physicians'  Interpreter,  we  append  the  Index  : — 


General  health i. 

Special  diet 31. 

Age  of  patient 52 

Necessity  of  patients  undergoing  an  opera- 
tion   63 

Office  hours 7i 

Days  of  the  week 78-  84 

Patient's  history:   hereditary  affections  in  his 
family;  his   occupation;    diseases   from 

his  childhood  up 85-130 

Months  of  the  year. 106-117 

Seasons  of  the  year 118-121 

Symptoms  of  typhoid  fever ..131-158 

Symptoms  of  Bright's  disease 159-168 

Symptoms  of  lung  diseases 169-194  and  311-312 

Vertigo 195-201 

The  eyes 201-232 

Paralysis  and  rheumatism 236-260 

Stomach  complaints  and  chills 26 1-269 


Falls  and  fainting  spells 271-277 

How  patient's  illness  began,  and  when  pa- 
tient was  first  taken  sick 278-279 

Names  for  various  parts  of  the  body 283-295 

The  liver 300-301 

The  memory 304-305 

Bites,  stings,  pricks 314-316 

Eruptions 317-318 

Previous  treatment 319 

Symptoms  of  lead-poisoning 320-324 

Hemorrhages 325-328 

Burns  and  sprains 33°-33i 

The  throat.. 33Z-335 

The  ears 336-339 

General    directions    concerning     medicines, 
baths,     bandaging,    gargling,     painting 

swelling,  etc 34'*-373 

Numbers pages  202-204 


The  work  is  well  done,  and  calcnlated  to  be  of  great 
service  to  those  who  wish  to  acquire  familiarity  with  the 
phr.ises  used  in  questioning  patients.  More  than  this,  we 
telieve  it  would  be  a  great  help  in  acquiring  a  vocabulary 
to  be  used  in  reading  medical  books,  and  that  it  would  fur- 
nish an  excellent  basis  for  beginning  a  study  of  any  one  of 
the  languages  which  it  includes. — ^Medical  and  Surgical 
Reporter. 

Many  other  books  of  the  same  sort,  with  more  ex- 
tensive vocabularies,  have  been  publislied.  but,  from  their 
size,  and  from  their  being  usually  devoted  to  equivalents 
in  English  and  one  other  language  only,  they  have  not  had 
the  advantage  which  is  pre-eminent  in  this — convenience. 
It  is  handsomely  printed,  and  bound  in  flexible  red  leather 
in  the  form  of  a  diary.  It  would  scarcely  make  itself  felt 
in  one's  hip-pocket,  and  would  insure  its  bearer  against  any 
«rdin.ary  conversational  difficulty  in  dealing  with  foreign- 
speaking  people,  who  are  constantly  coming  into  our  city 
hospitals. — Neio  York  3ledical  Journal. 

In  our  larger  cities,  and  in  the  whole  Northwest,  the 
physician  is  constantly  meeting  with  immigrant  patients, 
t»  whom  it  is  difficult  for  him  to  make  himself  understood, 
•r  to  know  what  they  Bay  in  return.    This  difficulty  will 


Phy. 


be  greatly  obviated  by  use  of  this  little  work.- 
sician  find  Surgeon. 

The  phrases  are  well  selected,  and  one  might  practice 
long  without  requiring  more  of  these  languages  than  this 
little  book  furnishes.— PAJta.  Mediral  T'mux. 

How  often  the  physician  is  called  to  attend  those  with 
whom  the  English  language  is  unfamiliar,  and  manv  pliy- 
sicians  are  thus  deprived  of  the  means,  save  through  an 
interpreter,  of  arriving  at  a  correct  knowledge  on  which  t« 
base  a  diagnosis.  An  interpreter  is  not  alwa3's  at  hand, 
but  with  this  pocket  interpreter  in  vour  hand  you  are  able 
to  ask  all  the  questions  necessarv,  and  receive  the  answer 
in  such  manner  that  you  will  be' able  to  fully  comprehend. 
—  The  .Vediniil  Brief. 

This  little  volume  is  one  of  the  most  ingenious  aids' 
to  the  physician  which  we  have  seen.  We  heartil.v  com- 
mend the  book  to  any  one  who,  being  without  a  knowledge 
of  the  foreign  languages,  is  obliged  to  treat  those  who  do 
not  know  our  own  language. — St.  Louis  Courier  of  Medi- 
cine. 

It  will  rapidly  supersede,  for  the  practical  use  of  the 
doctor  who  cannot  take  the  time  to  learn  another  language, 
all  other  suggestive  works. — Chicago  Medical  Times. 


18 


(F.  A.  DAVIS,  Medical  Publisher,  Philadelphia,  Pa.,  U.S.A.) 


An  Important  Aid  to  Students  in  the  Study  of  Anatomy. 

Three  Chart5  or 

The  Nervo-Vascular  System. 

l^ART  I.— THE  JSEBVBS, 

PABT  II.— THE  ABTEBIES. 

I'ABT  III.— THE  VEINS. 

Arranged  by  W.  HENRY  PRICE,  A.M.,  M.D.,  AND  S.  POTTS  EAGLETON. 
ENDORSED  BY  LEADING  ANATOMISTS. 


PRICE,  IN  THE  UNITED  STATES  AND  CANADA,  50  CENTS,  NET,  COMPLETE; 
GREAT  BRITAIN,  2s.  6d.     FRANCE,  3  fr.  60. 

TEE  NERVO-VASCULAR  SYSTEM  OF  CHARTS "  far  Escels  Every  Other  System 
in  their  Completeness,  Compactness,  and  Accuracy. 


I*(l7't  I.  The  JVerves. — Gives  in  a  clear  form  not  only  the  Cranial 
and  Spinal  Nerves,  showing  the  formation  of  the  different  Plexuses 
and  their  branches,  but  also  the  complete  distribution  of  the 
fe^MP ATRETIC  Nerves,  thereby  rhaking  it  the  most  complete  and 
concise  chart  of  the  Nervous  System  yet  published. 

Part  II.  The  Arteries. — Gives  a  unique  grouping  of  the  Arterial 
System,  showing  tlie  divisions  and  subdivisions  of  all  the  A^essels, 
beginning  from  the  heart  and  tracing  their  continuous  distribution 
to  the  periphery,  and  showing  at  a  glance  the  terminal  branches 
of  each  artery. 

Part  III.  The  Veins. — Shows  how  the  blood  from  the  periphery 
of  the  bod}-  is  gradvially  collected  by  the  larger  veins,  and  these 
coalescing  forming  still  larger  vessels,  until  the}'  finall}'  trace 
themselves  into  the  Right  Auricle  of  the  heart. 

It  is  therefore  readily  seen  that  "  The  Nervo-Yascular  System  of 
Charts  "  offers  the  following  superior  advantages : — 

1.  It  is  the  only  arrangement  which  combines  the  Three  Systems, 
and  yet  each  is  perfect  and  distinct  in  itself. 

2.  It  is  the  onlj'  instance  of  the  Cranial,  Spinal,  and  Sympathetic 
Nervous  Systems  being  represented  on  one  chart. 

3.  From  its  neat  size  and  clear  t^rpe,  and  being  printed' only  upon 
one  side,  it  may  be  tacked  up  in  any  convenient  place,  and  is  always 
ready  for  freshening  up  the  memory  and  reviewing  for  examination. 

4.  The  nominal  price  for  w-hich  these  charts  are  sold  places  them 
within  the  reach  of  all. 

For  the  student  of  anatomy  there  can  possibly  be  no  ;    veins  of  the  human  body,  giving  names,  origins,  distribu- 

more  concise  way  of  acquiring  a  knowledge  of  the'nerves,  ;    tions,  and  functions,  very  convenient  as  memorixers  and 

veins,  and  arteries  of  the  human  system.     It  presents  at  a  reminders.    A  similar  series,  jnepared  by  the  late  J.  H. 

glance  their  trunks  and  branches  in  the  great  divisions  of  Armsby,  of  Albany,  N.Y.,  and  framed,  long  found  a  place 

the  body.     It  will  save  a  world  of  tedio\is  reading,  and  wili  in  the  study  of  the  writer,  and  on  more  than  one  occasion 

impress  itself  on  the  mind  as  no  ordinary   i(/</<i  mccum,  was   the   means  of   saving  precious   moments  that  must 

even,  could.     Its  jirice  is  nominal  and  its  value  inestima-  otherwise  have  been  devoted  to  tumbling  the  pages  of  ana- 

ole.    .No  student  should  be  witliout  it. — Pacific  Record  of  ■     tomical  works. — ^J'<I.  Age. 

ilKdifint  and  Surgcri/.  _,           .,             i.     .        -n    l       ^ 

^    "  These    three    charts  will   be   of  great    assistance  to 

We  tnke  pleasure  in  calling  attention  to  these  charts.  • :    medical  students.     They  can  be  hung  on  the  wall  and  read 

as  they  are  so  arranged  that  a  study  of  them  will  serve  to  1 1    across  any  ordinary  room.    The  price  is  only  fifty  cents  for 
impress  them  more  indellibly  on  your  mind  than  can  be 
5ained   in   any  other  nay.    They   are  also  valuable  for 
reference. — Medical  Brief. 


These  are  three  admirably  arranged  charts  for  the 
■se  of  students,  to  assist  in  memorizing  their  anatomical 
atudies.— iiii/ufo  )Ied.  and  .Surg.  Jour. 

This  is  a  series  of  charts  of  the  nerves,  arteries,  and 


the  set. — Practice. 

These  charts  have  been  carefiilly  arranged,  and  will 
prove  to  be  very  convenient  for  ready  reference.  Tliey 
are  three  in  number,  each  constituting*  a  part.  .... 
It  is  a  high  recommendation  that  these  cliaits  have  been 
examined  and  approved  by  John  B.  Dcaver.  M.D..  Demon- 
strator of  Anatomy  in  the  University  of  Pennsylvania. — 
Pacific  Med.  and  Surg.  Jour,  and  Wealern  Lancet. 


(F.  A.  DAVIS,  Medical  Publisher  Philadelphia,  Pa..  U.S.A.)  19 


EVERY    .SANITARIAN   SHOULD    HAVE    ROHK'S   "TEXT-BOOK    OF    HYGIENE" 
AS  A   WORK  OF  REFERENCE. 


sEcoisTiD  JoiDxrrxoisr. 


-^insr  ^i^Ess. 


TEXT-BOOK  OF  HYGIENE: 

A  COMPREHENSIVE  TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE  OF  PREVENTIVE  MEDICINE 
FROM  AN  AMERICAN  STAND-POINT. 

By    OHOROH    H.    ROHH,    M.D., 

Professor  of  Obstetrics  and  Hygiene  in  the  College  of  Physicians  ami  Surgeon*.  Baltimore ;  Director  of  the  Maryla»i 

Maternite  ;  Member  of  the  Americim  Public  Health  Association  ;  Foreign  Associate  of  the  Societe  Fran^aise 

d'Hygiene,  of  the  Societe  des  Cheraliers-Sauveteurs  des  Alpes  Maritimes,  etc. 

Net  Price,   In  the  United  States,  iS3.50;   in  Canada  (dnty  paid),  »2.75 ;    in 
Great  Britain,  lis.  3d. ;  France,  16  tr.  20. 


Second  Edition — Thoroughlv  Revised  and  Largely  Rewritten,  with  many  Illustrations 
AND  Valuable  Tables.  Rohe's  Hygiene  is  the  Standard  Text-Book  in  many  Medical  Colleges  in  the 
United  States  and  Canada.  It  is  a  sound  guide  to  the  most  modern  and  approved  practice  in  Applied 
Hygiene.  This  New  Edition  -will  be  issued  early  in  the  Spring  of  1890,  in  one  handsome 
Octavo  volume  of  about  400  p.ages,  bound  in  Extra  Cloth.  Read  what  competent  critics  have  said  of  the 
first  edition  of  Rohe's  "Text-Book  of  Hygiene": — 


A  storehouse  of  facts. — British  Mrdiral  Journal. 

Of  invaluable  assistance  to  the  stnient.—Saniiary  News. 

This  interesting  and  valuable  book.— Paci^c  Medical 
and  Snrffiriil  Journrlf^ 

Based  upon  sound  principles  and  good  practice.— PAito- 
delphid  Meiliriil  Times. 

Full  of  important  matter,  told  in  a  very  interesting 
manner. — .Science . 

In  harmony  with  the  most  recent  advances  in  pathology. 
—Medical  Tfmes  and  Gazette,  London. 


Nothing  better  for  the  teacher,  practitioner,  or  student. 
— Missiistppi  Valley  Medical  Monthly. 

Contains  a  mass  of  information  of  the  utmost  impor- 
tance.^./.7*:/f/)enrf^/i(  Practitioner. 

Just  the  work  needed  by  the  medical  student  and  the 
busy,  active,  sanitary  officer. — .Southern  Practititmer. 

This  very  useful  work. — American  ./our.  Med.  .Scie.nres. 

Comprehensive  in  scope,  well  condensed,  clear  in  style, 
and  abundantly  supplied  with  references. — Journal  Amer- 
ican Medical  Association. 


JXJST  issu£:d 


PHYSICIANS'  AND   STUDENTS'    READY-REFERENCE   SERIES 

- — 3sro.  ^. — 

The  Neuroses  of  the  Genito-Urinary  System 

WITH  STERILITY  AWD   I3II*OTEWCE. 


DR.     R.     ULTZrvIANN, 

Professor  of  Genito-Urinary  Diseases  in  the  Univeksity  of  Vienna. 
TRANSLATED,  WITH  THE  AUTHOR'S  PERMISSION,  BY 

GARDNER  W.  ALLEN,  M.D., 

Surgeon   in   the  Genito-Urinary   Department   Boston    Dispensary. 


lUastrated.    ISmo.   Handsomely  Bound  in  Darli-Blne  Cloth.   Net  Price,  in  the  Unite«l 
States  and  Canada,  $1.00,  Post-paid  ;  Great  Britain,  4s.  6d.  ;  France,  6  fr.  20. 


This  great  work  upon  a  subject  which,  notwithstanding  the  great  .stride.?  that  have 
been  made  m.its  investigation  and  the  deep  interest  it  pos.sesses  for  all,  is  nevertheless 
still  but  imperfectly  understood,  has  been  translated  in  a  most  perfect  manner,  and  pre- 
serves most  fully  the  inherent  excellence  and  fascinating  style  of  its  renowned  and 
lamented  author.  Full  and  complete,  yet  terse  and  concise,  it  handles  the  subject  with 
such  a  vigor  of  touch,  such  a  clearness  of  detail  and  description,  and  such  a  directness  to 
the  result,  that  no  medical  man  who  once  takes  it  up  will  be  content  to  lay  it  down  until 
its  perusal  is  complete, — nor  will  one  reading  be  enough. 

Professor  Ultzmann  was  recognized  as  one  of  the  greatest  authorities  in  his  chosea 
specialty,  and  it  is  a  little  singular  that  so  few  of  his  writings  have  been  translated  into 
English.  Those  who  have  been  so  fortunate  as  to  benefit  by  his  instruction  at  the  Vienna 
Polyclinic  can  testify  to  the  soundne.ss  of  his  pathological  teachings  and  the  success  of  his 
methods  of  treatment.  He  approached  the  subject  from  a  somewhat  different  point  of 
view  from  most  surgeons,  and  this  gives  a  peculiar  value  to  the  work.  It  is  believed, 
moreover,  that  there  is  no  convenient  hand-book  m  English  treating  in  a  broad  manner 
the  Genito-urinary  Neuroses. 

SYNOPSIS  OF  CONTENTS.  First  Part.— I.  Chemical  Changes  in  the  Urine  i« 
Cases  of  Neuroses.  II.  The  Neuroses  of  the  Urinary  and  of  the  Sexual  Organs,  classi- 
fied as :  1,  Seneory  Neuroses  ;  2,  Motor  Neuroses ;  3,  Secretory  Neuroses.  Second  Part, — 
Sterility  and  Impotence. 

The  Treatment  in  all  Cases  is  Described  Clearly  and  Minutely. 


20 


CF.  A.  DAVIS,  Medical  Publisher,  Philadelphia,  Pa.,  U.S.A.) 


Hay  Fever 


ITS  SUCCESSFUL   TREATMENT   BY   SUPERFICIAL   ORGANIC 
ALTERATION  OF  THE  NASAL  MUCOUS  MEMBRANE. 


CMARI^KS  E.  SAJOUS,  M.D., 

Lecturer  on  Rhinology  and  Lnryngologr  in  Jefferson  Medical  College ;  Vice-President  of  the  American  Laryngological 

Association ;  "Oificer  of  the  Academy  of  France  and  of  Public  Instruction  of  Venezuela  i  Corresponding 

Member  of  the  Royal  Society  of  Belgium,  of  the  Medical  Society  of  Warsaw  (Poland), 

and  of  the  Society  of  Hygiene  of  France  :  Member  of  the  American 

Philosophical  Society,  etc.,  etc. 


WITH    13    ENGRAVINGS    ON    WOOD.       13ino.      BOUND    IN    CLOTH.     BEVELED 

EDGES.     PKICE,    IN    UNITED   STATES    AND   CANADA,    NET,  Sl.OO; 

GREAT   BRITAIN,  48.    3d.;    FRANCE,    6  fr.  20. 


The  object  of  this  little  work  is  to  place  in  the  hands  of  the  general 
practitioner  the  means  to  treat  successfull}^  a  disease  which,  until  lately, 
was  considered  as  incurable ;  its  history,  causes,  pathology,  and  treat- 
ment are  carefully  described,  and  the  latter  is  so  arranged  as  to  be 
practicable  b}^  any  physician. 


Dr.  Sajous'  volume  must  command  the  attention  of 
those  called  upon  to  treat  this  heretofore  intractable  com- 
plaint.— Medical  and  Surgical  ReportT. 

Few  have  had  the  success  in  this  disease  which  has 
so  much  bafHed  the  average  practitioner  as  Dr.  Sajous,  con- 
sequently his  statements  are  almost  authoritative.  The 
book  must  be  read  to  be  appreciated. — American  Medical 
Digest. 

^  Dr.  Sajous  has  admirably  presented  the  subject,  and, 
as  this  method  of  treatment  is  now  generally  recognized 
as  efficient,  we  can  recommend  this  book  to  .all  physicians 


who  are  called  upon  to  treat  this  troublesome  disorder. — 
The  Buffalo  Medical  and  Surgical  Journal. 

The  symptoms,  etiology,  pathology,  and  treatment  of 
Hay  Fever  are  fully  and  ably  discussed.  Tiie  reader  will 
not  regret  the  expenditure  of  the  small  purchase  price  of 
this  work  if  he  has  cases  of  the  kind  to  treat.— C'a/i/orni"a 
Medical  Journal. 

We  are  pleased  with  the  author's  views,  and  heartily 
commend  his  book  to  the  consideration  of  the  profession. 
— The  Southern  Clinic. 


PHYSICIANS'   AND  STUDENTS'   READY    REFERENCE  SERIES. 


I^^o.    1.= 


OBSTETRIC  SYNOPSIS. 

By  JOHN  S.  STEWART,  M.D., 

Demonstrator  of  Obstetrics  and  Chief  Assistant  in  the  GynjECological  Clinic  of  the  Medico-Chirurgical 

College  of  Philadelphia. 

WITH   AN    INTRODUCTORY   NOTE  BY 

"WILLIAM  S.  STEWART,  A.M.,  M.D., 

Professor  of  Obstetrics  and  Gynaecology  in  the  Medico-Chirurgical  College  of  Philadelphia. 


42  ILLUSTRATIONS.    202  PAGES.    12 mo.    HANDSOMELY  BOUND  IN  DARK-BLUE  CLOTH. 

Pi-ice,  Post-paid,  in  the  United  States  and  Canada,  Net,  $1.00; 
Great  Britain,  4s.  3d. ;  France,  6  fr.  20. 


By  students  this  work  will  be  found  particularly  useful.  It  is  based 
upon  the  teachings  of  such  well-known  authors  as  Play  fair,  Parvin, 
Lush,  Galabin,  and  Cazeaux  and  Tarnier,  and,  besides  containing  much 
new  and  important  matter  of  great  value  to  both  student  and  practi- 
tioner, embraces  in  an  Appendix  the  Obstetrical  Nomenclature  sug- 
gested by  Professor  Simpson,  of  Edinburgh,  and  adopted  by  the 
Obstetric  Section  of  the  Ninth  Internationaf  Medical  Congress  held  in 
Washington,  D.C.,  September,  1887. 


It  is  well  written,  excellently  illustrated,  and  fully  up 
to  date  in  every  respect.  Here  we  find  .ill  the  essentials  of 
Obstetrics  in  a  nutshell.  Anatomy,  Embryology,  Physi- 
ology. Pregnancy,  Labor,  Puerperal  State,  and  Obstetric 
Operations  all  being  carefully  and  accurately  described. — 
Buffalo  Medical  and  Surgical  Journal. 

It  is  clear  and  concise.  The  chapter  on  the  develop- 
ment of  the  ovum  is  especially  satisfactory.  The  judicious 


use  of  bold-faced  type  for  headings,  and  italics  for  impor- 
tant statements,  gives  the  book  a  pleasing  typographical 
appearance.— J/cfiicai  Record. 

This  voiume  is  done  with  a  masterly  hand.  The 
scheme  is  an  excellent  one.  .  .  .  The  whole  is  freely 
and  most  admirably  illustrated  with  well-drawn,  new 
engravings,  and  the  book  is  of  a  very  convenient  size.— 
St.  Louis  Medical  and  Surgical  Journal. 


(F.   A.  DAVIS.   Medical  Publisher.  Philadelphia.  Pa..  U.  S.  A.) 


21 


DIPHTHERIA: 

Croup,  Tracheotomy,  ah^  Intubation. 

FROM   THE    FRENCH    OF  A.   SANNE. 

TRANSLATED  AND  ENLARGED  BY 

HENRY    Z.    OILL,    IVI.D.,    IvL.D. 


United  States.     Canada  (duty  paid).     Great  Britain.        France. 

Net  Price,  Post-paid,  Cloth,    -       -$4.00.  $140.  £  0.18s.        24  fr.  60 

"  "        Leather,    -        5.00.  ^.50.  1.  Is.        30  fr.  30 


The  above  work,  recently  issued,  is  a  translation  from  the  French  of  Sanne's  great 
work  on  "  Diphtheria,"  by  H.  Z.  Gill,  late  Professor  of  Surgery  in  Cleveland,  Ohio. 

Sanne's  work  is  quoted,  directly  or  indirectly,  by  every  writer  since  its  publication, 
as  the  highest  authority,  statistically,  theoretically,  and  practically.  The  translator, 
having  given  special  study  to  the  subject  for  many  years,  has  added  over  fifty  pages,  in- 
cluding the  Surgical  Anatomy,  Intubation,  and  the  recent  progress  in  the  branches 
treated  down  to  the  present  date;  making  it,  beyond  question,  the  most  complete  work 
extant  on  the  subject  of  Diphtheria  in  the  English  language. 

Facing  the  title-page  is  found  a  very  fine  Colored  Lithograph  Plate  of  the  parts  con- 
cerned in  Tracheotomy.  Next  follows  an  illustration  of  a  cast  of  the  entire  Trachea,  and 
bronchi  to  the  third  or  fourth  division,  in  one  piece,  taken  from  a  photograph  of  a  case 
in  which  the  cast  was  expelled  during  life  from  a  patient  sixteen  years  old.  This  is  the 
most  complete  cast  of  any  one  recorded. 

Over  fifty  other  illustrations  of  the  surgical  anatomy  of  instruments,  etc.,  add  to  the 
practical  value  of  the  work. 

Diphtheria  having  become  such  a  jirevalent,  wide-spread,  and  fatal  disease,  no 
general  practitioner  can  afford  to  be  without  this  work.  It  will  aid  in  preventive  meas- 
ures, stimulate  promptness  in  the  application  of,  and  efficiency  in,  treatment,  and 
moderate  the  extravagant  views  which  have  been  entertained  regarding  certain  specifics 
in  the  disease  Diphtheria. 

A  full  Index  accompanies  the  enlarged  volume,  also  a  List  of  Authors,  making 
altogether  a  very  handsome  illustrated  volume  of  over  680  pages. 


In  this  book  we  have  a  complete  review  and 
compendium  of  all  worth  preserving  that  has  hitherto 
been  said  or  written  concerning  diphtheria  and  the 
kindred  subjects  treated  of  by  our  author,  collated, 
arranged,  and  commented  on  by  both  author  and 
translator.  The  subject  of  intubation,  so  recently 
revived  in  this  country,  receives  a  very  careful  and 
impartial  discussion  at  the  hands  of  the  translator, 
and  a  most  valuable  chapter  on  the  prophylaxis  of 
diphtheria  and  croup  closes  the  volume. 

His  notes  are  frequent  and  full,  displaying  deep 
knowledge  of  the  subject-matter.  Altogether  the 
book   is   one  that   is  valuable  and  timely,  and  one 


Sanne's  work  is  quoted,  directly  or  indirectly, 
by  many  writers  since  its  publication,  as  the  highest 
authority,  statistically,  theoretically,  and  practi- 
cally. The  translator,  having  given  special  study 
to  the  subject  for  many  years,  has  added  over  fifty 
pages,  including  the  surgical  anatomy,  intubation, 
and  the  recent  progress  in  the  branches  treated, 
down  to  the  present  date;  making  it,  beyond  ques- 
tion, the  mo.st  complete  work  extant  on  the  subject 
of  diphtheria  in  the  English  language.  Diphtheria 
having  become  such  a  prevalent,  wide-spread,  and 
fatal  disease,  no  general  practitioner  can  afford  to 
be   without    this    work.     It    will    aid    in    preventive 


that  should  be  in  the  hands  of  every  general  practi-    |   measures,  stimulate  promptness  in  application  of,  and 
tioner. — Si.  Louis  Med.  and  Surgical  Journal.         j    efficiency  in,  treatment. — Southern  Practitioner. 

STANTON'S  PRACTICAL  ANO  SCIENTIFIC  mWWM 

OP 

By  MARY  OLMSTED  STANTON. 


Copiously  Illustrated.  T-wo  r.arg:e  Octavo  Volumes. 

United  States.       Canada  (duty  paid).       Great  Britain.  France. 

Price,  per  Volume,  Cloth,  $5.00  $5.50        .  £l.ls.  30  fr.  3» 

.     «  "  Sheep,  6.00  6.60  1.6s.  36  fr.  40 

«  "  Half-Kussia,  7.00  7.70  1.9s.  43  fr.  30 

$1.00  Discount  for  Cash.    Sold  only  by  Subscription,  or  sent  direct  on  receipt  of  price,  shipping  expenses  prepaid. 


The  author,  Mrs.  Mary  O.  Stanton,  I\as  given  over  twenty  years  to  the  preparation  of  this  work.  Her 
style  is  easy,  and,  by  her  happy  method  of  illustration  of  every  point,  the  book  reads  like  a  novel,  and 
memorizes  itself.  To  physicians  the  diagnostic  information  conve5'ed  is  invaluabh.  To  the  general 
reader  each  page  opens  a  new  train  of  ideas.     (This  book  has  no  reference  whatever  to  Phrenology.) 


2t2  iF.  A.  DAVIS,  Medical  Publisher,  Philadelphia,  Pa..  U.S.A.) 


innpoFix.A.ia'x  .AlNnoxtncei^snt. 


A  treatise: 

— ox — 

Materia  Medica,  Pharmacology,  i  Therapeutics. 

BY 

dOHN  Vy.  SHOEMAKER,  A.M.,   M.D., 

Professor  of  Materia  Medica,  Pharmacology,  and  Therapeutics  in  the  Medico-Chirurgical  College  of  Phila- 
delphia, and  Member  American  Medical  Association, 

AND 

dOMN    AULDE,    M.D., 

•emonstrator  of  Clinical  Medicine  and  of  Physical  Diagnosis  in  the  Medico-Chirurgical  College  of  Phila- 
delphia, and  Member  American  IMedical  Association. 


IN  TWO  HANDSOME  ROYAL  OCTAVO  VOLUMES. 

NET  PRICES,  per  Volume,  in  United  States:  Cloth,  S2.50;  Sheep,  S3. 25.     In  Canada 

(duty  paid)  :  Cloth,  )»2.75  ;  Sheep,  $3.55.     In  Great  Britain:  Cloth,  lis.  3d.  ; 

Sheep,  14s.  6d.     In  France:  Cloth,  16  fr.  20;  Sheep,  20  fr.  20. 


THE  Publisher  takes  pleasure  in  announcing  that  Volume  I  of  this  eagerly-looked-for 
work  is  Now  Ready,  and  that  the  utmost  diligence  will  be  exercised  in  filling  with 
*he  greatest  rapidity,  and  in  regular  order  of  receipt,  the  numerous  orders  now  awaiting 
its  publication. 

The  general  plan  of  the  work  embraces  three  parts,  each  of  which  is  practically  inde- 
pendent of  the  other,  as  will  be  understood  from  the  accompanying  analysis,  and  of  which 
Parts  I  and  II  are  contained  in  the  volume  now  announced  ;  this,  however,  is  not  the  only 
advantage  accruing  from  the  preparation  of  the  work  in  two  volumes.  Each  volume  will 
thus  be  much  smaller  and  more  convenient  to  handle,  while  some  may  wish  to  secure  a 
particular  portion  of  the  work,  and  to  them  the  cost  is  lessened. 

Several  blank  sheets  of  closely -ruled  letter-paper  are  inserted  at  convenient  places  in 
the  work,  thus  rendering  it  available  for  the  student  and  physician  to  add  valuable  notes 
concerning  new  remedies  and  other  important  matters. 

Part  I  embraces  three  subdivisions,  as  follow : — 

First.  A  brief  synopsis  upon  the  subject  of  pharmacy,  in  which  is  given  a  clear  and 
concise  description  of  the  operations  and  preparations  taken  into  account  by  the  physician 
when  prescribing  medicines,  together  with  some  practical  suggestions  regarding  the  most 
desirable  methods  for  securing  efficiency  and  palatability. 

Second.  A  Classification  of  Medicines  is  presented  under  the  head  of  "General  Phar- 
macology and  Therapeutics,"  with  a  view  to  indicate  more  especially  the  methods  by 
which  the  economy  is  affected.  Thus,  there  are  Internal  and  External  Remedies,  and. 
besides,  a  class  termed  Chemical  Agents,  including  Antidotes,  Disinfectants,  and  Anti- 
septics, and  an  explanatory  note  is  appended  to  each  group,  as  in  the  case  of  AKeratives, 
Antipyretics,  Antispasmodics,  Purgatives,  etc. 

Third.  A  Summary  has  been  prepared  upon  Therapeutics,  covering  methods  of 
Administration,  Absorption  and  Elimination,  Incompatibility,  Prescription-writing,  and 
Dietary  for  the  Sick,  this  section  of  the  work  embracing  nearly  one  hundred  and  fifty 
pages. 

Part  II  is  devoted  to  "  Remedies  and  Remedial  Agents  Not  Properly  Cla.-;sed  with 
Drugs."  and  includes  elaborate  articles  upon  the  following  topics :  Electro-Therapy, 
Hy(fro-Therapy,  Masso-Therapy,  Heat  and  Cold,  Oxygen,  ]\Iineral-Waters,  and,  in  addi- 
tion thereto,  other  subjects,  perhaps  of  less  significance  to  the  practitioner,  such  as  Clima- 
tology, Hypnotism  and  Suggestion,  Metallo-Therapy,  Transfusion,  and  Baunscheidtisnius, 
have  received  a  due  share  oi  attention.  This  section  of  the  work  embraces  over  two  hun- 
dred pages,  and  will  be  found  especially  valuable  to  the  student  and  recent  graduate,  as 
these  articles  are  fully  abreast  of  the  times. 

Volume  II,  which  is  Part  III  of  the  work,  is  wholly  taken  up  with  the  consideration 
©f  drugs,  each  remedy  being  studied  from  three  points  of  view,  viz.,  the  Preparations,  or 
Materia  Medica;  the  Physiology  and  Toxicology,  or  Pharmacology,  and,  lastly,  its 
Therapy.     It  will  be  Ready  about  May  1,  1890. 

The  typography  of  the  work  will  be  found  clean,  sharp,  and  easily  read  without 
injury  to  the  visual  organs,  and  the  bold-face  type  interspersed  throughout  the  text  makes 
the  different  subjects  discussed  quick  of  reference.  The  paper  and  binding  will  also  be  u\> 
to  the  standard,  and  nothing  will  be  left  undone  to  make  the  work  first-class  in  every 
particular, 

CF.  A.  DAI/IS,  Medical  Publisher,  Philadelphia,  Pa.,  U.S  A.)  23 


iJUST   PUBLISHED.: 


THE  PHYSIOLOGY 

OF  THE 

Domestic  Animals. 

A  TEXT-BOOK  FOR  VETERINARY  AND  MEDICAL 
STUDENTS  AND  PRACTITIONERS. 

— BY — 

ROBERT  MEADE  SMITH,  A.M.,  M.D., 

Professor  of  Comparative  Physiology  in  University  of  Pennsylvania  ;  Fellow  of  the  C'ollege  of  Physicians 

and  Academy  of  the  Natural  Sciences,  Philadelphia  ;  of  the  American  X'hysiological 

Society  ;  of  the  American  Society  of  Naturalists  ;  Associe  Etranger 

de  la  Societe  Frangaise  D'  Hygiene,  etc. 


liG.  117. — Parotid  and  Submaxillary  Fistula  in  the  Horse,  after  Colin. 

(Thanhoffer  and  Tor  may .) 

K.  K',  rubber  bulbs  for  collecting  saliva;  cs,  cannula  in  the  parotid  duct. 


In  One  Handsome  Royal  Octavo  Volume  of  over  950  Pages,  Pro- 
fusely Illustrated   -with   more   than   400   Fine   "Wood- 
Engravings  and  many  Colored  Plates. 

United  States.        Canada  (duty  paid).        Great  Britain.  France. 

NET  PRICES,  CLOTH, $5.00  $5.50  £1.  30  fr.  30 

SHEEP, 6.00  6.60  1.6.  36  fr.  20. 


'THIS  new  and  important  work,  the  most  thoroughly  complete  in  the  English  language 
on  this  subject,  has  just  been  issued.  In  it  the  physiology  of  the  domestic  animals 
is  treated  in  a  most  comprehensive  manner,  especial  prominence  being  given  to  the  sub- 
ject of  foods  and  fodders,  and  the  character  of  the  diet  for  the  herbivora  under  different 
conditions,  with  a  full  consideration  of  their  digestive  peculiarities.  Without  being  over- 
burdened with  details,  it  forms  a  complete  text-book  of  physiology,  adapted  to  the  use  of 
students  and  practitioners  of  both  veterinary  and  human  medicine.  This  work  has  already 
heen  adopted  as  the  Text-Book  on  Physiology  in  the  Veterinary  Colleges  of  the  United 
States,  Great  Britain,  and  Canada. 

24  (F.  A.  DAVIS,  Medical  Publisher,  Philadelphia,  Pa.,  U.S.A.) 


Ab5TRACT5    FROn   KeV!EW5*^5m1TH'5   PhY5I0L0QY. 


^^ 


-Ecr 


The  work  throughout  is  well  balanced. 
Broad,  though  not  encyclopasdic,  concise 
without  sacrificing  clearness,  it  combines 
the  essentials  of  a  successful  text-book.  It 
is  eminently  modern,  and,  although  first  in 
the  field,  is  of  such  grade  of  excellence  that 
successors  must  reach  a  high  standard  be- 
fore they  become  competitors. — Annals  of 
Surgery. 

Dr.  Smith  has  conferred  a  great  benefit 
upon  the  veterinary  profession  by  his  con- 
tribution to  their  use  of  a  work  of  immense 
value,  and  has  provided  the  American  vet- 
erinary student  with  the  only  means  by 
which  he  can  become  properly  familiar  with 
the  physiology  of  our  domestic  animals. 
Veterinary  practitioners  and  graduates  will 
read  it  with  pleasure.  Veterinary  students 
will  readily  acquire  needed  knowledge  from 
it.«  pages,  and  veterinary  schools  which 
would  oe  well  equipped  for  the  work  they 
aim  to  perform  cannot  ignore  it  as  their 
text-booK  in  physiology. — American  Veteri- 
nary Review. 

Dr.  Smith's  presentment  of  his  subject 
IS  as  brief  as  the  status  of  the  science  per- 
mit.-*, and  to  this  much-desired  conciseness 
he  has  added  an  equally  welcome  clearness 
of  statement.  The  illustrations  in  the  work 
are  exceedingly  good,  and  must  prove  a 
valuable  aid  to  the  full  understanding  of 
the  text. — Journal  of  Comparative  Medicine 
and  Surgery. 

We  have  examined  the  work  in  a  great 
many  particulars,  and  find  the  views  so 
correct,  where  we  have  had  the  means  of 
comparison  of  statements  with  those  of  some 
recognized  authority,  that  we  will  be  com- 
pelled hereafter  to  look  to  this  work  as  the 
text-book  on  physiology  of  animals.  The 
book  will  prove  of  incalculable  benefit  to 
veterinarians  wherever  they  may  be  found; 
and  to  the  country  physician,  who  is  often 
called  upon  to  attend  to  sick  animals  as 
well  as  human  beings,  we  would  say,  lose 
no-  time  in  getting  this  work  and  let  him 
familiarize  himself  with  the  facts  it  con- 
tains.—  Virginia  Medical  Monthly. 

Altogether,  Professor  Smith's  "  Physi- 
ology of  the  Domestic  Animals"  is  a  happy 
production,  and  will  be  hailed  with  delight 
in  both  the  human  medical  and  veterinary 
medical  worlds.  It  should  find  its  place 
besides  in  all  agricultural  libraries. — Paul 
Paqufn,  M.D.,  Vs.,  in  the  Weekly  Melical 
Beview. 

It  may  be  said  that  it  supplies  to  the 
veterinary  student  the  place  in  physiology 
that  Chauveau's  incomparable  work — "  The 
Comparative  Anatomy  of  the  Domesticated 
Animals" — occupies  in  anatomy.  Higher 
praise  than  this  it  is  not  possible  to  bestow. 
And  since  it  is  true  that  the  same  laws  of 
physiology  which  are  applicable  to  the  vital 
prof-ess  of  the  domestic  animals  are  also  ap- 
plicable to  man,  a  perusal  of  this  carefully 
wi  itn-n  book  will  rejiuy  the  medical  student 
or  luartiliniir-i- — (^a.nadian  Practitioner. 


The  work  before  us  fills  the  hiatus  of 
which  complaint  has  so  often  been  made, 
and  gives  in  the  compass  of  less  than  a 
thousand  pages  a  very  full  and  complete 
account  of  the  functions  of  the  body  in  both 
carnivora  and  herbivora.  The  author  has 
judiciously  made  the  nutritive  functions  the 
strong  point  of  the  work,  and  has  devoted 
special  attention  to  the  subject  of  foods  and 
digestion.  In  looking  through  the  other 
sections  of  the  work,  it  appears  to  us  that  a 
just  proportion  of  space  is  assigned  to  each, 
in  view  of  their'  relative  importance  to  the 
practitioner.  Thus,  while  the  subject  of  re- 
production is  dismissed  in  a  few  pages,  a 
chapter  of  considerable  length  is  devot«d 
to  locomotion,  and  especially  to  the  gaits  of 
the  horse. — London  Lancet. 

This  is  almost  the  only  work  of  the  kind 
in  the  English  language,  and  it  so  fully 
covers  every  detail  of  general  and  special 
physiology  that  there  is  no  room  for  any 
rival.  The  excellence  of  typographical 
work,  and  the  wealth,  beauty,  and  clear- 
ness of  the  illustrations,  correspond  with 
the  thoroughness  and  clearness  of  the 
treatise. — Albany  Medical  Annals. 

It  is  not  often  that  the  medical  profes- 
sion has  the  opportunity  of  reading  a  new 
book   upon   a  new  subject,  and  doubtless 
English-speaking  physicians  will  feel  grate- 
ful to    Professor   Smith    for  his  admirable 
and   ])ioneer  work  in  a  branch  of  medical 
science  ujion  which  a  great  ainou'At  of  ignor- 
ance prevails.     .     .     .     The  last  portion  of 
the  work    is   devoted   to  the  reproductive 
functions,  and  contains  much  valuable  in- 
formation upon  a  portion  of  animal  physi- 
ology concerning  which  many  are  ignorant. 
The  book  is  a  valuable  one  in  every  way, 
and  will  be  consulted  largely  by  veterinary 
and  medical  students  and   practitioners. — 
Buffalo  Medical  and  Surgical  Journal. 
1       The  appearance  of  this  work  is  most  op- 
portune.    It  will  be  much  appreciated,  as 
I  tending  to  secure  the  thorough  comprehen- 
I  sion  of  function    in    the  domesticated  ani- 
mals,   and,    in   consequence,  their   general 
well-being — a  matter  of  world-wide  impor- 
1  tance.     With  a  thorough  sense  of  gratifica- 
I  tion  we  have  perused  its  pages:  throughout 
!  we  find  clear  expression,  clear  reasoning, 
I  and  that  patient  accumulation  of  facts  so 
valuable    in    a   text -book   for   students. — 
'  British  Medical  JournaL 

\  For  notice  this  time,  I  take  up  the  vol- 
ume  on   the  "  Physiology  of  the  Domestic 

1  Animals,"  by  Dr.  R.  Meade  Smith,  a  vohnne 
of  988  pages,  closely  printed,  and  dealing 

j  with  its  subject  in  a  manner  sufficiently  ex- 

!  haustive  to  insure  its  place  as  a  text-book 
for  fifteen  years  at  tlie  very  least.  Its 
learning  is  only  equaled  by  its  industry, 
and  its  industry  by  the  consistency  and 
skill  with  wtiichits  varied  parts  are  brouuht 
together  into  harmonious,  lucid,  and  in- 
tellectual unity.— Dr.  BEN.i.'iMrN  Ward 
Richardson,  in  the  /..ondon  Asclepiod. 


^^- 


rS^ 


(F.   A.  DAVIS.    Medical  Publisher,   Philadelphia.   Pa..   U.S.A.) 


THE;  — — 

International  Pocket  Medical  Fopmulapj), 

ARRANGED   THERAPEUTICALLY. 

By  G.  SUMNER  WlTHERSTlNE,   M.S.,   M.D., 

Associate  Editor  of  the  "Aiimuil  of  tlic  Universal  Mcdital  Sciences  ;"   Visiting  I'hysician  of  the  Home  for 
the  Aged,  (jermantuun,  Philadelphia;  I. ate  House-Siirgeon  Charily  Hospital,  New  York. 

More  than  1800  Formulae  from  Several  Hundred  Well-Known  Authorities. 

With  an  Appendix  containing  a  Posological  Table,  the  newer  remedies  included  ;  Important  Incompati- 
bles  ;  Tables  on  Dentition  and  the  Pulse  :  Table  of  Drops  in  a  Fluidrachni  and  Doses  of  Laudanum  graduated 
lor  age  ;  Formula;  and  Doses  of  Hypodermic  Medication,  including  the  newer  remedies;  Uses  of  the  Hypo- 
dermic Syringe  ;  Formula;  and  Doses  for  Inhalations,  Nasal  Douches,  (largles,  and  Eye-washes  ;  Formula; 
for  Suppositories;  Use  of  the  Thermometer  in  Disease;  Poisons,  Antidotes,  and 'I'reatment ;  Directions  for 
Post-Mortem  and  Medico-I.egal  Examinations  ;  Treatment  of  Asphyxia,  Sun-stroke,  etc.  ;  Anti-emetic 
Remedies  and  Disinfectants;  Obstetrical  Table;  Directions  for  Ligation  of  Arteries  ;  Urinary  Analysis; 
Tabic  of  Eruptive  Fevers  ;  Motor  Points  for  Electrical  Treatment,  etc.,  etc. 

■J'his  work,  the  best  and  most  complete  of  its  kind,  contains  about  875  prmte<l  pages,  besides 
extra  blank  leaves.  Elegantly  printed,  with  red  lines,  edges,  and  borders;  with  illustrations.  Itound 
ill  leather,  wltli  .side  flap.     It  contains  more  than  1800  Forinuhe,  exclusive  of  the  large  amount  of 

other  very  valuable  matter. 

Price,  Post-paid,  in  the  United  States  and  Canada,  $2.00,  net ; 
Great  Britain,  8s.  6d. ;  France,  12  fr.  40. 

TTN  PP/IQnM^   WHY  EVERY  MEDICAL  MAN  SHOULD  POSSESS  A  COPY  OF 

I  c/r  ncHouno     j^^  international  pocket  medical  formulary. 

1.     Because  it  is  a  handy  book  of  reference,  replete  with  the  choicest  formula;   (over  igoo  in  number)  of 
more  than  six  hundred  of  the  most  prominent  classical  writers  and  modern  practitioners, 

3.  Because  the  remedies  given  are  not  only  those  whose  efficiency  has  stood  the  test  of  time,  but  also  the 
newest  and  latest  discoveries  in  pharmacy  and  medical  science,  as  prescribed  and  used  by  the  best- 
known  American  and  foreign  modern  authorities. 

3.  Because  it  contains  the  latest,  largest  (66  formulae)  and  most  complete  collection  of  hypodermic  formula; 

(including  the  latest  new  remedies)  ever  published,  with  do.ses  and  directions  for  their  use  in  over 
fifty  different  diseases  and  diseased  conditions. 

4.  Because  its  appendi,x  is  brimful  of  information,  invaluable   in  office  work,  emergency  cases,  and  the 

daily  routine  of  practice. 

5.  Because  it  is  a  reliable  friend  to  consult  when,  in  a  perplexing  or  obstinate  case,  the  usual  line  of  treat- 

ment is  of  no  avail.  (A  hint  or  a  help  from  the  best  authorities,  as  to  choice  of  remedies,  correct 
dosage,  and  the  eligible,  elegant,  and  most  palatable  mode  of  exhibition  of  the  same. ) 

6.  Because  it  is  compact,  elegantly  printed  and  bound,  well  illustrated,  and  of  convenient  size  and  shape 

for  the  pocket. 

7.  Because  the  alphabetical  arrangement  of  the  diseases  and   a  thumb-lciter  index  render  reference  rapid 

and  ea.sy. 

8.  Because  blank  leaves,  judiciously  distributed  throughout  the  book,  afford  a  place  to  record  and  index 

favorite  formula;. 

9.  Because,  as  a  student,  he  needs  it  for  study,  collateral  reading,  and  for  recording  the  favorite  pre.scriptions 

of  his  professors,  in  lecture  and  clinic  :  as  a  recent  graduate,  he  needs  it  as  a  reference  hand-book  for 
daily  use  in  prescribing  (gargles,  nasal  douches,  inhalations,  eye-washes,  suppositories,  incompatibies, 
poisons,  etc.)  ;  as  an  old  practitioner,  he  needs  it  to  refresh  his  memory  on  old  remedies  and  combi- 
nations, and  for  information  concerning  newer  remedies  and  more  modern  approved  plans  of  treatment. 

10.  Because  no  live,  progressive  medical  man  can  afford  to  be  without  it. 


It  is  sometimes  important  that  such  prescriptions  as 
have  been  well  established  in  their  usefulness  be  preserved 
for  refereiK-e.  and  thi.«  little  volume  serves  such  a  purpose 
better  than  any  other  we  have  seen.— Co/H/niH.s  Medical 
.TournaL 

Without  doubt  this  book  is  the  best  one  of  its  class 

that  we  have  ever  seen The  printins.  binding. 

and  general  appearance  of  the  volume  are  beyond  praise.— 
University  Malicnl  Magazine. 

It  may  be  possible  to  get  more  crystallized  knowledge 
in  an  equally  small  space,  but  it  does  not  seem  probable.— 
Medical  Classicn. 

A  very  handy  and  valuable  book  of  formulae  for  the 
physician's  pocket. — S^  Lmtix  Medical  and  Surf/.  .TournaL 

This  little  pocket-book  contains  an  immense  number 
of  prescriptions  taken  from  high  authorities  in  this  and 
other  countries.— jVo;7/iiCftWcrn  Lancet. 

This  one  is  the  most  complete  as  well  as  the  most 
conveniently  arranged  of  any  that  have  come  under  our 
attention.  The  diseases  are"  enumerated  in  alphabetical 
order,  and  for  each  the  latest  and  most  approved  remedies 
from  the  ablest  authorities  are  prescribed.  The  book  is  in- 
dexed entirely  through  after  the  order  of  the  first  pages  of 
a  ledger,  the  index  letter  being  printed  on  morocco  leather 
and  therebv  made  very  dur.able.- Pa'-i^c  Medical  .TournaL 

It  is  a  book  desirable  for  the  old  practitioner  and  for 
his  vounger  brothers  as  well.— S^  Joseph  Medical  Herald. 


As  long  as  '-combinations"  are  sought  such  a  book 
will  be  of  value,  especially  to  those  who  cannot  spare  the 
time  rei|nired  to  learn  enough  of  incompjitibilities  before 
commencing  practice  to  avoid  writing  incompatible  and 
dangerous  prescriptions.  The  constant  use  of  such  a  book 
by  such  prescribers  would  save  the  pharmacist  much 
anxiety. — The  Druf/fjists'  Circular. 

In  judicious  selection,  in  accurate  nomenclature,  in 
arrangement,  and  in  style  it  leaves  nothing  to  be  desired. 
The  editor  and  the  publisher  are  to  be  congratulated  on  the 
production  of  the  very  best  book  of  its  class.— Pi/fc^ftw/j/A 
Medical  Rerieic. 

One  must  see  it  to  realize  how  much  Information  can 
be  got  into  a  work  of  so  little  bulk.— t'oHafto  Medical 
Record. 

To  the  voung  phvsician  just  starting  out  in  practice 
this  little  book  will"  prove  an  a«ceptable  companion.— 
Omaha  Clinic. 

The  want  of  to-day  is  crvstallized  knowledge.  This 
neat  little  volume  contains  in  it  the  most  ac<;essible  form. 
It  is  bound  in  morocco  in  pocket  form,  with  alphabetical 
divisions  of  disca.ses.  so  that  it  is  possible  to  turn  instantly 
to  the  remedy,  whatever  may  be  the  ilisorder  or  wherever 

the  patient  may  be  situated To  the  physician 

it  is  invaluable,  and  others  should  not  l.c  without  it.  We 
heartily  commend  the  work  to  our  ivaders— .tfi»«<-iio'« 
Medical  Journal. 


■26 


fF.  A.  DAVIS,  Medical  Publisher,  Philadelphia,  Pa..  USA 


JXJST    ISSUED-  = 

PHYSICIANS'    AND    STUDENTS'    READY-REFERENCE    SERIES. 

iTo.  3. 

S^aiopsis  of  Human  Anatomy: 

Being   a  Complete   Compend  of  Anatomy,  including-  the 
Anatomy  of  the  Viscera,  and  Numerous  Tables. 


JAUES   K.  YOUNG,  M.O., 

Instructor  in  (Jrthopaedic  Surgery  and  Assistant    Demonstrator  of  Surgerj',  University  of  Pennsylvaaia; 
Attending  Orthopsedic  Surgeon,  Qut-Patienl  Department,  University  Hospital,  etc. 


ILLUSTRATED  WITH  76  WOOD-ENGRAVINGS.     390  PAGES. 

12 mo.     HANDSOMELY  BOUND    IN    DARK-BLUE   CLOTH. 

Price.  Post-paid,  in  the  United  States  and  Canada,  $1.40,  net; 
.     Great  Britain,  6s.  6d.  ;  France,  9  fr.  25. 


While  tlie  author  has  prepared  this  work  especial!}^  for  students,  sufficient  de- 
scriptive matter  has  been  added  to  render  it  extremely  valuable  to  the  busy  practitioner, 
]>articularly  the  sections  on  tiie  Viscera,  Special  Senses, 
and  Surgical  Anatomy. 

The  work  includes  a  complete  account  of  Osteology, 
Articulations  and  Ligaments,  Muscles,  Fascias,  Vascular 
and  Nervous  Sj'stems,  Alimentary.  Vocal,  and  Kespiratory 
and  Genito-Urinarv  Apparatuses,  the  Organs  of  Special 
Sense,  and  Surgical  Anatomy. 

In  addition  to  a  most  carefully  and  accurately  prepared 
•text,  wherever  possible,  the  value  of  the  work  has  bee.n 
enhanced  by  tables  to  facilitate  and  minimize  the  labor  of 
students  in  acquiring  a  thorough  knowledge  of  this  impor- 
tant subject.  The  section  on  the  teeth  has  also  been 
es|iecially  prepared  to  meet  the  requirements  of  students 
of  Dentistry. 

In  its  preparation,  Gray's  Anatomy  [last  edition], 
edited  by  Keen,  being  the  anatomical  work  most  used,  has 
been  taken  as  the  standard. 


Anatomy  is  a  theme  that  allows  such  concen- 
tration better  than  most  medical  subjects,  and,  as 
the  accuracy  of  this  little  book  is  beyond  question, 
its  value  is  assured.  As  a  companion  to  the  dis- 
secting-table,  and  a  convenient  reference  for  the 
practitioner,  it  has  a  definite  field  of  usefulness. — 
Pittsburgh  Medical  Re-uieiu. 

This  is  a  very  carefully  prepared  compend  of 
.matomy,  and  will  be  useful  to  students  for  college 
or  hospital  examination.  There  are  some  excellent 
tables  in  the  work,  particularly  the  one  showing  the 
origin,  course,  distribution,  and  functions  of  the 
cranial  nerves. — Medical  Record. 

Dr.  Young  has  compiled  a  very  useful  book. 
We  .are  not  inclined  to  .approve  of  compends  as  a 
gener.al  rule,  but  it  certainly  serves  a  good  purpose 
to  have  the  subject  of  anatomy  presented  in  a  com- 
pact, reliable  way,  and  in  a  book  easily  carried  to 
the  dissecting-room.  This  the  author  has  done, 
i'he  book  is  well  printed,  and  the  illustrations  well 
selected  if  a  student  can  indulge  in  more  than  one 
work  on  .anatomy, — for,  of  course,  he  must  have  a 
general  treatise  on  the  subject, — he  can  hardly  do 
better  than  to  purcha-se  this  compend  It  will  save 
the  larger  work,  and  can  always  be  with  him  during 
the  hours  of  dissection. — Buffalo  Medical  and 
Surgical  yourttal. 


Excellent  tables  have  been  arranged,  which 
tersely  and  clearly  present  important  anatomical 
facts,  and  the  book  will  be  found  very  convenient 
for  ready  reference— Coluvibus  Medical  Journal. 

The  book  Is  much  more  satisfactory  than  the 
"remembrances"  in  vogue,  and  yet  is  not  too  cum- 
bersome to  be  carried  around  and  read  at  odd 
moments — a  propeny  which  the  student  will  readily 
appreciate.  —  H'eekly  Medical  RevieT.v. 

If  a  synopsis  of  human  anatomy  may  serve  a 
purpose,  and  we  believe  it  does,  it  is  very  imponant 
that  the  synopsis  should  be  a  good  one.  In  this 
respect  the  above  work  may  be  recommended  as  a 
reliable  guide.  Dr.  Young  has  shown  excellent 
judgment  In  his  selection  of  illustrations,  in  the 
numerous  tables,  and  in  the  classification  of  the 
various  subjects.— 7y/cr-(i/f«//<:  Gazette. 

Every  unnece.ssary  word  has  been  excluded,  out 
of  regard  to  the  very  limited  time  at  the  medical 
student's  disposal.  It  is  also  good  as  a  reference 
book,  as  it  presents  the  facts  about  which  he  wishes 
to  refresh  his  memory  in  the  briefest  manner 
consistent  with  clearness. — New  York  Medical 
"jfournal 

It  is  certainly  concise  and  accurate,  and  should 
be  in  the  hands  of  everv  student  and  practitioner. — 
The  Medical  Brief. 


(F.  A.  DAVIS.  Medical  Publisher.  Philadelphia.  Pa..  U.S.A.) 


ANNUAL     -    

OF    IHH 

Universal  ]Vl*^'dical  S'^it^^^^'*^-"^- 

A     YEARLY   REPORT    OF    THE   PROGRESS   OF    THE   GENERAL    SANITARY 
SCIENCES  THROUGHOUT  THE  WORLD. 

Edited   by    CHARLES   E.    SAJOUS,    M.  D., 

LBi  Tl'NKK    ON    I.AKYNGOLOGY  AND    RHINOLOGY    IN    JKFFHKS<JN    MBDICAL   COLLEGE,   PHILAIJELHHI A,  HTC. 

AND 

SEVENTY    ASSOCIATE    EDITORS, 

Assisted  b7  over  TWO  HUNDRED  Corresponding  Editors  and  Collaborators. 

In  Five  Royal  Octavo  Volumes  of  about  500  pages  each,  hound  in  Cloth  and  Half-RuKHia, 

Magnificently  Illustrated  with  Chromo-Lithographs,  Engravings, 

Maps,  Charts,  and  Diagrams. 

^-      BEIT^O    IXTTEIVPEP ^ 

1st.  To  assist  the  busy  practitioner  in  liis  efforis  to  kee])  abreast  of  the  lapid  strides 
of  all  the  branches  of  his  profession. 

2d.  To  avoid  for  him  the  loss  of  time  involved  in  searching  for  that  which  is  new  in 
the  profuse  and  constantly  increasing  medical  literature  of  our  day. 

8d.  To  enable  him  to  obtain  the  greatest  possible  benefit  of  the  liraiUvi  time  lie  i.** 
able  to  devote  to  reading,  by  furnishing  him  with  new  matter  only. 

4th.  To  teep  him  informed  of  the  work  done  by  all  nations,  including  jnany  other- 
wise seldom  if  ever  heard  from. 

5th.  To  furnish  him  with  a  review  of  ail  the  new  matter  contained  in  the  ])eriodicals 
10  which  he  cannot  (through  their  immense  number)  subscribe. 

(Hh.  To  cull  for  the  specialist  all  that  is  of  a  progressive  nature  in  the  general  and 
special  ]>ublications  of  all  nations,  and  obtain  for  him  special  reports  from  countries  in 
which  such  publications  do  not  exist,  and 

Lastly,  to  enable  any  physician  to  ])0ssess,  at  a  moderate  cost,  a  complete 

CONTEMPORARY  HISTORY  OP  UNIVERSAL  MEDICINE, 

edited  by  many  of  America's  ablest  teachers,  and  superior  in  every  detail,  of  print,  paper, 
binding,  etc.,  etc.,  a  befitting  continuation  of  such  great  works  as  "  Pepper  s  System  of 
Medicine,"  "Ashhurst's  International  Encyclopasdia  of  Surgery,"  "  Buck's  Reference 
Harid-Book  of  the  Medical  Sciences,"  etc.,  etc. 

EDITORIAL  STAFF  of  the  ANNUAL  of  the  UNIVERSAL  MEDICAL  SCIENCES. 

ISSUE    OP    1888. 
Chief  Kditor,  DK.  CHARLES  E.  SAJOUS,  Philadelphia 

Volunae  I. — Obstetrics,  Oynatcology,  Pediatrics,  Anatomii,  Physiology,  Pa.thelogy. 
Histology ,  and  Em  bryology. 

Prof.  Wm.  L.  Richardson,  Boston.  Prof.  William  Goodell  and  Dr.  W.  C.  i  Prof.  H.  Newell  Martin  and  Dr.  W.  H. 
Prof.  TheophiluB  Parvin,  Philada.  Goodell.  Philadelphia.  Howell,  Baltimore. 

Prof.  l,<juia  Starr.  Philadelphia.  Prof.  E.  C.  Dudley,  Cliica^'u.  Dr.  Chas.  S.  Minot,  Boston. 

Prof.  J.  Lewis  Smith,  New  York  City.  Prof.  W.  H.  Parish,  Philadelphia.  Dr.  E.  O.  Shakespeare.  Philadelphia. 

Prof.  Paal  F.  Munde  and  Dr.  E.  H.  Prof.  William  S.  Forbes.  Philadelphia.      Dr.  W.  X.  Sudduth.  Philadelphia. 
Grandin,  New  York  City. 

Volume  II. — Diseases  of  the  Respirdtory,  Circulatory,  Digestive,  and  JVervovs  /■^sterns; 
Fevers,  Exanthemata,  etc.,  etc. 


Prof.  A.  L.  Loomis,  New  York  City. 
Prof.  Jas.  T.  Whittaker,  Cincinnati. 
Prof.  W.  H.  Thomson,  New  York  City. 
Prof.  W.  W.  John.ston,  Washington. 
Prof  Jos.  Leidy,  Philadelphia. 


Prof.  E.  C.  Seguin,  New  York  City.  Prof.  Jas.  Tyson,  Philadelphia. 

Prof.  E.  C.  Spitzka,  New  York  City.       .  Prof.  N.  S.  Davis,  Chicago. 
Prof.Chas.K.  Millsand Dr.  J.H.Lloyd,      Prof.  John  Guiteras.  Charleston,  S.  C. 


Philadelphia.  !  Dr.  Jas.  C.  Wilson.  Philadelphia. 

Prof.  Francis  Delafield,  N.  Y.  City. 

Volunae  III. — General  Surgery,  Venereal  Diseases,  Ancesthetics,  Surgical  Dressings, 

Dietetics,  etc..  etc. 


Prof.  D.  Hayes  Agnew,  Philadelphia,  i  Prof.  F.  R.  Sturgis,  New  York  City.  Prof.  T.  G.  Morton  and  Dr.  Wm.  Hunt, 

Prof.  Hnnt«r  McGuire,  Richmond.  I  Prof.  N.  Senn,  Milwaukee.  Philadelphia. 

Prof.  Lewis  A.  Stim.son,  New  York.  Prof.  J.  E.  Garretsou,  Philadelphia.  i  Dr.  Morris  Longstreth,  Philadelphia. 

Prof.  P.  S.  Conner,  Cincinnati.  Prof.  Christopher  Johnston,  Baltimore.  Dr.  Chas.  Wirgman,  Philadelphia. 

Prof.  J.  EwingMears.  Philadelphia.  i  Dr.  Chas.  B.  Kelsey,  New  York  City.  Dr.  C.  C.  Davidson.  Philadelphia. 
Prof.  E.  L.  Keyes,  New  York  City. 

Volume  IV. — Ophthalmology,  Otology,  Laryngology,  Rhinology,  Dermatology,  Dentistry, 
Hygiene,  Disposal  of  the  Dead,  etc.,  etc. 

Prof.  William  Thomson,  Philadelphia,  i  Prof.  C.  N.  Peirce,  Philadelphia.  Dr.  Chas.  S.  Turnbull,  Philadelphia. 

Prof.  J.  Solis  Cohen,  Philadelphia.  \  Prof.  John  B.  Hamilt<in,  Washington.  Dr.  Edw.  C.  Kirk.  Philadelphia. 

Prof.  D.  Bryson  Dolavan,  New  York.      I  Prof.  H.  M.  Lvman,  Chicago.  Dr.  John  G.  Lee,  Philadelphia. 

I'rof.  A.  Van  Harlingen,  Philadelphia.     Prof.  9.  H.  Guilford.  Philadelphia.  Dr.  Chas.  E.  Sajous.  Phila<ielphia. 

28 


List  of  Collaborators  to  Dental  Department. 

Prof  James  Truman.  Philadelphia.  Prof.  E.  H.  Angle,  Minneapolis.  Minn.     Dr.  J.  D.  Patteraon.  Kansas  City,  iVIo. 

Prof.  J.  A.  Marshall,  Chicago,  111.  Prof.  J.  E.  Cravens.  Indianapolis.  Ind.     Dr.  J.  B.  Hodgkin,  Washington,  D.  C. 

Prof  A  W.  Harlan.  Chicago,  111.  Prof.  R.  Stubblefield,  Nashville.  Tenn.     Dr.  R.  R.  Andrews.  Cambridge,  Mass. 

Prof.  G.  V.  Black,  Chicago.  III.  Prof.  W.  C.  Barrett.  Butfalo.  X.  Y.  Dr.  Albion  M.  Dudley.  Salem.  Mass. 

Prof  C  H   Stowell,  Ann  Arbor.  Mioh.  Prof.  A.  H.  Thompson.  Topeka.  Kan.        Dr.  Geo.  S.  Allen,  New  York  City. 

Prof  L.  C.  Ingersoll,  Xeokuk.  Iowa.  Dr.  James  W.  White,  Philadelphia.        ,  Dr.  G.  S.  Dean,  San  Francisco,  Cal. 

Prof  F  J   S.  Gorgas.  Baltimore.  Md.  Dr.  L.  Ashley  Faught.  Philadelphia.       i  Dr.  M.  H.  Fletcher,  Cincinnati.  Ohio. 

Prof  H  A   Smith   Cincinnati.  Ohio.  Dr.  Robert  S.  Ivy,  Philadelphia.  i  Dr.  A.  Morsman.  Omaha.  Neb. 

Prof.  C.  P.  Pengra,  Boston.  Ma.'is.  Dr.  W.  Storer  How,  Philadelphia.  j  Dr.  G.  W.  .Melotte,  Ithaca,  N.  Y. 

Volume  V. — General  and  Experimental  Therapeutics,  Medical  Chemistry,  Medical 
Junsprudence,  Demography,  Gliinatology.  etc.,  etc. 

Prof.  William  Pepper,  Philadelphia.  ,  Prof.  George  H.  Rohe,  Baltimore.  Dr.  W.  P.  Mantou,  Detroit,  Mich. 

Prof  F  W.  Draper,  Boston.  \  Dr.  Albert  L.  Gihon,  V.  S.  N.  Dr.  Hobart  A.  Hare,  Philadelphia. 

Prof.  J.  W.  Holland,  Philadelphia.  Dr.  R.  J.  DangUson,  Philadelphia.  Dr.  C.  S.  Witberstine,  Philadelphia. 
Prof.  .\.  L.  Rannev,  New  York  City. 


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EXTRACTS    FROM    REUIEWS. 

We  venture  to  say  that  all  who  saw  the  Annual  as  it  ai)peared  in  1888  were  oa  the 
lookout  for  its  reappearance  this  (1889)  year;  but  there  are  many  whose  knowledge  of  this 
magnificent  undertaking  will  date  witli  this  present  issue,  and  to  those  a  mere  examina- 
tion of  the  work  will  suffice  to  shoV  that  it  fills  a  legitimate  place  in  the  evolution  of 
knowledge,  for  it  does  what  no  single  individual  is  capable  of  doing. 

These  volumes  make  readily  available  to  the  busy  practitioner  the  best  fruits  of 
medical  progress  for  the  year,  selected  by  able  editors  from  the  current  literature  of  the 
world;  such  a  work  cannot  be  overlooked  by  anyone  who  would  keep  abreast  of  the 
times.  With  so  much  that  is  worthy  of  notice  incorporated  in  one  work,  and  each  depart- 
ment written  up  with  a  minuteness  and  thoroughness  appreciated  particularly  by  the 
specialist,  it  would  avail  nothing  to  cite  particular  instances  of  progress.  Let  it  be  suffi- 
cient to  say,  however,  that  while  formerly  there  was  a  possible  excuse  for  not  having  the 
latest  information  on  matters  pertaining  to  the  medical  sciences,  there  can  no  longer  be 
such  an  excuse  while  the  Annual  is  published. — Journal  of  the  American  Medical 
Association. 

We  have  before  us  the  second  issue  of  this  Annual,  and  it  is  not  speaking  too 
strongly  when  we  say  that  the  series  of  five  volumes  of  which  it  consists  forms  a  most 
important  and  valuable  addition  to  medical  literature. 

Great  discretion  and  knowledge  of  the  subjects  treated  of  are  required  at  the  hands 
of  those  who  have  taken  charge  of  the  various  sections,  and  the  manner  in  which  the 
gentlemen  who  were  chosen  "to  fill  the  important  posts  of  sub-editors  have  acquitted 
themselves  fully  justifies  the  choice  made.  We  know  of  no  branch  of  the  profession  to 
which  this  Annual  could  fail  to  be  useful.  Dr.  Sajous  deserves  the  thanks  of  the  whole 
profession  for  his  successful  attempt  to  facilitate  the  advance  of  medical  literature  and 
practice. — London  Lancet. 

This  very  valuable  yearly  report  of  the  progress  of  medicine  and  its  collateral 
sciences  throughout  the  world  is  a  work  of  very  great  magnitude  and  high  importance. 
It  is  edited  by  Dr.  C.  E.  Sajous,  assisted,  it  is  stated,  by  seventy  associate  editors,  whose 
names  are  given,  making  up  a  learned  and  most  weighty  list.  Their  joint  labors  have 
combined  to  produce  a  series  of  volumes  in  which  the  current  progress  throughout  the 
world,  in  respect  to  all  the  branches  of  medical  science,  is  very  adequately  represented. 
The  general  arrangements  of  the  book  are  ingenious  and  complete,  having  regard  to 
thoroughness  and  to  facility  of  bibliographical  reference, — British  Medical  Journal. 


ANNUAL,   1890. 

The  editor  and  publishers  of  the  Annual  of  the  Universal 
Medical  Sciences  take  this  opportunity  to  thank  its  numerous  friends 
and  patrons  for  the  liberal  support  accorded  it  in  the  past,  and  to 
announce  its  publication,  as  usual,  in  1890.  Recording,  as  it  does,  the 
progress  of  the  world  in  medicine  and  surgery,  its  motto  continues  to 
be,  as  in  the  past,  "  Improvement,"  and  its  friends  may  rest  assured  that 
no  eftbrt  will  be  spared,  not  onl}^  to  maintain,  but  to  surpass,  the  high 
standard  of  excellence  already  attained. 

The  Subscription  Price  will  be  the  same  as  last  year's  issue  and 
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(F.  A.  DAVIS,  Medical  Publisher.  Philadelphia,  Pa.,  U.S.A.)  29 


ISSUK    OK    1HH9 

OP 

The  Annual  of  the  Universal  Medical  Sciences. 

Ill    Kivp    Itoyal    Octavo   Volumes    of  over   500  pages  each,  botiiul  in  Cloth  and 

llalf-KiiniNia,  3Ia>;»ifi<'e'»tl.v  Illustrated  with   Chi-oiiio-L.ithog;rai>hs, 

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XHE    SAXEI.I.IXE 

— OF     llll-. — 

AI^JBilTAI,    OK    THE    UNIVERSAI^    9I£»ICAL    SCIETVCES. 

\  .\lonihly  Review  of  the  mo.st  important  articles  upon  the  practical  branches  of  medicine  appearing  in 
the  medical  press  at  large,  edited  by  the  Chief  Editor  ot  the  Annual  and  an  able  staff. 


Editorial  Staff  of  the  Annual  of  the  Universal  Medical  Sciences,  issue  of  1889. 

Chief  Editor,  Dr.  CHAS.  E.  SAJOUS,  Philadelphia. 

jPLSSOOIjfiLTE:    STjfiLli'ir'. 

Volume  I. — Diseas&s  of  the  Lungs,  Diseases  of  the  Heart,  Diseases  of  the  Gastro- 
Hepatic  System,  Diseases  of  the  Intestines,  Intestinal  Entozoa,  Diseases  of 
ihe  Kidneys  and  Bladder,  Fevers,  Fevers  in  Children,  Diphtheria,  Rheu- 
matism and  Gout,  Diabetes,  Volume  Index. 

Piof.  Jas.  T.  Whittaker,  Cincinnati.  I  Dr.  Jas.  C.  Wilson,  Philadelphia. 

Prof.  A.  L.  I^omis,  New  York  City.  I  Prof  Louis  Starr,  Philadelphia. 

Prof.  E.  T.  Bruen,  Philadelphia.  Prof.  J.  Lewis  Smith,  New  York. 

Prof.  W.  W.  Johnston,  Washington.  i  Prof.  N.  S.  Davis,  Chicago. 

Dr.  I,.  Emmeit  Holt,  New  York.  Prof.  Jas.  Tyson,  Philadelphia. 

Prof.  Jos.  Leidy,  Philadelphia. 

"Volume  II.— Diseases  of  the  Brain  and  Cord,  Peripheral  Nervous  System,  Mental 
Diseases,  Inebriety,  Diseases  of  the  Uterus,  Diseases  of  the  Ovaries,  Diseases 
of  the  External  Genitals  in  Women,  Diseases  of  Pregnancy,  Obstetrics,  Dis- 
eases of  the  Newborn,  Dietetics  of  Infancy,  Growth,  Volume  Index. 

Prof.  E.  C.  Seguin,  New  York  City. 

Prof.  Henry  Hun,  Albany. 

Dr.  E.  N.  Brush,  Philadelphia. 

Dr.  W.  R.  Birdsall,  New  York. 

Prof.  Paul  F.  Munde,  New  York  City. 

Prof.  Wm.  Goodell.  Philadelphia. 


Prof  W.  H.  Parish.  Philadelphia. 
Prof.  Theophilus  Parvln,  Philadelphia. 
Prof  Wm.  L.  Richardson,  Boston. 
Dr.  A.  F.  Currier,  New  York. 
Prof.  Louis  Starr,  Philadelphia. 
Dr.  Chas.  S.  Minot,  Boston. 


Dr.  W.  C.  Goodell,  Philadelphia. 
Volume  III. — Surgery  of  Bram,  Surgery  of  Abdomen,  Genito-Urinary  Surgery,  Dis- 
eases of  Rectum  and  Anus,  Amputation  and  Resection  and  Plastic  Surgery, 
Surgical  Diseases  of  Circulation,  Fracture  and  Dislocation,  Military  Surgery, 
Tumors.  Orthopaedic  Surgery,  Oral  Surgery,  Surgical  Tuberculosis,  etc.,  Sur 
gical  Diseases,  Results  of  Railway  Injuries,  Anaesthetics,  Surgical  Dressings, 
Volume  Index. 


Prof.  N.  Senn,  Milwaukee. 
Prof.  E.  L.  Keye-s,  New  York  City. 
Prof.  J.  Ewing  Mears,  Philadelphia. 
Dr.  Chas.  B.  Kel-sey,  New  York  City. 
Prof.  P.  S.  Conner,  Cincinnati. 
Dr.  John  H.  Packard,  Philadelphia 
Prof  Lewis  A.  Stimson,  New  York  City. 
Dr.  J.  M.  Barton,  Philadelphia. 


Prof.  D.  Hayes  Agnew,lPhiIadelphia. 
Dr.  Morris  Ixjngstreth,  Philadelphia. 
Dr.  Thos.  G.  Morton,  Philadelphia. 
Prof.  J.  E.  Garretson,  Philadelphia. 
Prof.  J.  W.  White,  Philadelphia. 
Prof.  C.  Johnston,  Baltimore. 
Prof.  E.  C.  Seguin,  New  York  City. 


Volume  IV. — Skin  Diseases,  Ophthalmology,  Otology,  Rhinology,  Diseasas  of  Pharynx, 
etc.,  Intubation,  Diseases  of  Larynx  and  CEsophagus,  Diseases  of  Thyroid 
Gland,  Legal  Medicine,  Examination  for  Insurance,  Diseases  of  the  Blood, 
Urinalysis,  Volume  Index. 

Prof.  A.  Van  Harlingen,  Philadelphia.  I  Dr.  Chas.  E.  Sajous,  Philadelphia. 

Dr.  Chas.  A.  Oliver  and  Dr.  Geo.  M.  !  Prof.  D.  Bryson  Delavan,  New  York. 

Govdd,  Philadelphia.  Prof.  R.  Fletcher  Ingals,  Chicago. 

Dr.  Charles  S.  Turnbull,  Philadelphia.  Prof.  F.  W.  Draper,  Boston. 

Prof  J.  Solis  Cohen,  Philadelphia.  Prof.  Jas.  Tyson,  Philadelphia. 

Prof.  John  Guiteras,  Charleston,  S.  C.  ! 

Volume  V. — General  Therapeutics,  Experimental  Therapeutics,  Poisons,  Electric 
Therapeutics,  Climatology,  Dermography,  Technology,  Bacteriology,  Embry- 
ology, Physiology,  Anatomy,  General  Index. 

Dr.  C.  Sumner  Witherstine,  Philadelphia. 


T>r.  J.  P.  Crozer  Griffith,  Philadelphia. 
Dr.  Hobart  A.  Hare,  Philadelphia. 
Prof  Geo.  H.  Rohe.  Baltimore. 
Prof  John  B.  Hamilton,  Washington. 
Dr.  Harold  C.  Ernst,  Boston. 
Prof  H.  Newell  Martin,  Baltimore. 
Dr.  R.  J.  Dunglison,  Philadelphia. 


Prof.  J.  W.  Holland,  Philadelphia. 
Prof.  A    L.  Rannev,  New  York. 
Dr.  Albert  H.  Gihon.  C.  S.  N. 
Dr.  W.  P.  Manlon,  Detroit. 
Dr.  W.  X.  Sudduth,  Philadelphia. 
Prof  Wm.  T.  Forbes,  Philadelphia. 


m  (F.  A.  DAVIS,  Medical  Publisher.  Philadelphia,  Pa..  U.S.A.) 


THE  LATEST  BOOK  OF  EEFEBENCE  ON  NERVOUS  DISEASES. 


Lectures  on  Nervous  Diseases, 

FROM  THE  STAND-POINT  OF  CEREBRAL  AND  SPINAL  LOCALIZATION.  AND 

THE  LATER  METHODS  EMPLOYED  IN  THE  DIAGNOSIS  AND 

TREATMENT  OF  THESE  AFFECTIONS. 

By    /^^MBROSE    L.    RANNEY,   A.M.,   M.D., 

Prj.ct.sor  of  the  Anatomy  and  Physiology  of  the  Nervous  System  in  the  New  York  Post-Graduate  Medical 

School  and  Hospital  ;  Professor  of  Nervous  and  Mental  Diseases  in  the  Medical  Department  of  the 

University  of  Vermont,  etc   ;  Author  of  "The  Applied  Anatomy  of  the  Nervous  System," 

■'  Practical  Medical  Anatomy,"  etc.,  etc. 

r'I2,O^TrSEIj-S-    IXjX.-CrSTXa.A.TE3D 

With  Original  Diagrams  and  Sketches  in  Color  by  the  Author,  carefully  selected  Wood- 
Kng:ravings,  and  Reproduced  Photographs  of  Typical  Cases. 

ONE    HANDSOME    ROYAL   OCTAVO    VOLUME   OF    780    PAGES. 

United  States.  Cannda  (duty  paid).  fireat  Britain.  France. 

CLOTH,  -  -  -  «5.50  «6.05  «1.3s.  34  fr.  70 

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HALF-KUSSIA,  -  -  7.00  7.70  1.9s.  43  fr.  30 

SOLD  02<rij-5r  BY  stJBSCiJ-ii^Tioisr. 


It  is  now  generally  conceded  that  the  nervous  system  controls  all  of  the  physical 
functions  to  a  greater  or  lees  exleut,  and  also  that  most  of  the  symptoms  encountered  at 
the  bedside  can  be  explained  and  interpreted  from  the  stand-point  of  nervous  physiology. 

The  unprecedented  sale  of  this  work  during  the  short  period  which  has  elapsed  .'<inre 
it."!  publication  has  already  compelled  the  publishers  to  print  a  second  edition,  which  is 
already  nearly  exhausted. 

We  are  glad  to  note  that  Dr.  Ranney  has  pub-  |  appeared  in  medical  literature,  is  presented  in  com- 
)ishcd  in  ciok  form  his  admirable  lectures  on  nervous 
diseases.  His  book  contains  over  seven  hundred 
large  pages,  and  is  profusely  illustrated  with  origi- 
nal diagrams  and  sketches  in  colors,  and  with  many 
carefully  selected  wood-cuts  and  reproduced  photo- 
graphs of  typical  cases.  A  large  amount  of  valua- 
ble information,  not  a  little  of  which  has  but  recently 


pact  form,  and  thus  made  easily  accessible.  In  our 
opinion,  Dr.  Ranney's  book  ought  to  meet  with  a 
cordial  reception  at  the  hands  of  the  medical  pro- 
fession, for,  even  though  the  author's  views  may  be 
sometimes  open  to  question,  it  cannot  be  disputed 
that  his  work  bears  evidence  of  scientific  method  and 
honest  opinion. — American  Journal  of  Insattiiy. 


LECTURES 

ON    THE 

Diseases  of  the  Nose  and  Throat. 

DELIVERED  AT  THE  JEFFERSON  MEDICAL  COLLEGE,  PHILADELPHIA. 

By   CHARLES    E.  SAdOUS,   M.D., 

Lecturer  on  Rhinology  and  Laryngology  in  Jefferson  Medical  College;  Vice-Pi-esident  of  the  American  Larrugological 

Association :  Officer  of  the  Academy  of  France  and  of  Public  Instruction  of  Venezuela ;  Corresponding  Member 

of  the  Koyal  Society  of  Belgium,  of  the  Medical  Society  of  Warsaw  (Poland),  and  of  the  Society  of 

Hygiene  of  France  ;  Member  of  the  American  Philosophical  Society,  etc.,  etc. 


ILLUSTRATE!)  WITH  100  CHKOMO-LITHOGRAPHS,  FROM  OIL  PAINTINGS  BY 
THE  AUTHOR,  AND  93  ENGRAVINGS  ON  AVOOIX 

ONE  HANDSOME  ROTAIi  OCTAVO  VOLITME.  SOLD  ONLY  BY  SUBSCRIPTION. 


United  States. 

Canada  (duty  paid). 

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F.~ance. 

Cloth,  Royal  Octavo, 

S^.OO 

$4.40 

£0.18s. 

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5.00 

5.50    . 

1.   Is. 

30  fr.  30 

'Since  the  publisher  brought  this  valuable  tvork  before  the  profession,  it  has  become. 
1st,  the  text-book  of  a  large  number  of  colleges  ,•  ;?c?.  the  reference-book  of  the  U.  S.  Army, 
Navy,  and  the  Marine  Service ;  ami,  3d,  an  important  and  valued  addition  to  the  libraries 
of  over  7000  physicians. 

This  book  ha.s  not  only  the  inherent  merit  of  presenting  a  clear  expose  of  the  subject, 
but  it  is  written  with  a  view  to  enable  the  general  practitioner  to  treat  his  cases  himself. 
To  facilitate  diagnosis,  colored  plates  are  introduced,  showing  the  appearance  of  the  differ- 
ent parts  in  the  diseased  state  as  they  appear  in  nature  by  artificial  light.  No  error  can 
thus  be  made,  as  each  affection  of  the  nose  and  throat  has  its  representative  in  the  100 
rhromo-lithographs  presented.  In  the  matter  of  treatment,  the  indications  are  so  complete 
that  even  the  slightest  procedures,  folding  of  cotton  for  the  forceps,  the  use  of  the  ])robe, 
etc.,  are  clearly  explained. 

It  is  intended  to  furnish  the  general  practitioner    jj  they  would   appear  to   him   were  they  seen  in  the 

not  only  with  ?  guide  for  the  treatment  of  diseases  of  I  living  subject.     As  a  guide  to  the  treatment  of  the 

the  nose  and  throat,  but  also  to  place  before  him  a  nose  and  throat,  we  can  cordially  recommend  this 

representation  of  the  normal  and  diseased  parts  as  woTV.—Jioi/on  Medical aud  Surgica.1  yoiirnal. 

(F.  A.  DAVIS,  Medical  Publisher,  Philadelphia,  Pa..  U.S.A.)  31 


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IN   PRESS.     SECOND  EDITION.^ 


Ointments  and  Oleates  in  Diseases  of  the  Si^in. 

BV — 

dOHN  U.  SHOEMAKER,  A.M.,   M.D., 

Professor  of  Materia  Medica,  Pharmacology,  Therajientics,   and   Clinical  Medicine,  and  Clinical  Professor  of  Diseases 
of  the  Skin  in  the  Medico-Chirurgical  College  of  Philadelphia,  etc. 


16mo.    NEATLY  BOUND  IN  CLOTH.    PRICE,  IN  UNItED  STATES  AND  CANADA, 
NET,  $1.00,  POST-PAID  ;  GREAT  BRITAIN,  4».  3d. ;  FRANCE,  6  fr.  30. 

The  accompanying -Table  of  Contents  will  give  a  general  idea  of  the  work  : 
CJOISTTEXTTS.  Part  I. — History  and  Origin.  Part  II —Process  of  Manufacture.  Part 
HI. — Physiological  Action  of  the  Oleaths.  Part  IV. — Therapeutic  Effect  of  the  Oleates. 
Part  V. — Ointments:  Local  Medication  of  Skin  Di-seases. — Antiquity  of  Ointments. — Different  Indi- 
cations for  Ointments,  Powders,  Lotions,  etc. — Information  about  Ointments;  Scanty,  Scattered,  and 
Insufficient  — Kats  and  Oils:  Animal  and  Vegetable.— Their  Chemical  Composition.— Comparative 
Permeability  of  Oils  into  Skin  ;  of  Animal,  of  Vegetable.  Incorporation  of  Medicinal  Substances  into 
Fats:  (i)  Mode  of  Preparation,  (2)  Vegetable  Powders  and  Extracts,  (3)  Alkaloids,  (4)  Mineral  Sub- 
stances, (5)  Petroleum  Fats  ;  Chemical  Composition;  Uses  and  Disadvantages.— List  of  Officinal  Oint- 
ments.— Indications. — Substances  often  Prescribed  Extemporaneously  in  (Jintment  Form. — Indications. 
A  FULL  INDEX  RENDERS  THE  BOOK  CONVENIENT  FOR  QUICK  REFERENCE. 

CRITICISMS   OF   FIRST   EDITION. 

To  those  of  our  readers  who  wish  to  learn  the 
therapeutic  effects  of  a  class  of  preparations  which 
are  destined  to  grow  in  favor  as  their  merits  be- 
come more  generally  known,  we  commend  this 
book. — journal  of  Cutaneous  and  Venereal 
Diseases. 

No  physician  pretending  to  treat  skin  diseases 
should  be  without  a  copy  of  this  very  instructive 
little  book — Canada  Medical  Record. 


The  profession  in  both  countries  is  deeply  in- 
debted  to  Dr.  Shoemaker  for  his  excellent  work  in 
this  department  of  medicine. —  Williatn  Whitla, 
M.D.  (Q  U.I). 

It  is  the  most  complete  exposition  of  their  action 
which  has  yet  appeared.  They  are  very  valuable 
accessions  to  the  materia  medica,  and  should  be 
familiar  »o  every  practitioner. — Medical  and  Sur- 
gical Reporter. 


(F.  A.  DAVIS.  Medical  Publisher,  Philadelphia,  Pa.,  U.S.A.) 


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